Every finding on record at Cleveland Community Care Center

Based on record review, staff interview, and facility policy review the facility failed to ensure a resident who was admitted with multiple pressure ulcers and other wounds received necessary treatment and services to promote healing and prevent worsening by failing to obtain wound treatment orders and initiate wound care upon admission for one (1) of three (3) residents reviewed for pressure ulcers. Resident #1.Findings included:Record review of the facility policy Wound Care revealed Policy.Wound Care Orders and Care Plans. Each individual wound site requires a separate wound care order.A record review of progress notes for Resident #1, dated 4/17/26, revealed the resident refused assessment of her wounds. The physician was notified; however, there was no documentation that wound treatment orders were obtained.Further record review of a nursing progress note for Resident #1, dated 4/19/26, documented the resident had multiple wounds including a right heel pressure ulcer with slough, a right hip pressure ulcer with eschar, Stage four (4) pressure ulcers to the right buttock, sacrum, and left buttock with tunneling, and additional wounds to the lower extremities. Despite documentation identifying the wounds, no wound treatment orders were obtained.Record review of the April 2026 Order Summary Report for Resident #1 revealed no wound treatment orders were entered until 4/28/26.Record review of the April 2026 Treatment Administration Record (TAR) revealed no documented wound care treatments were provided prior to 4/22/26.Telephone interview on 6/8/26 at 3:39 PM, the Wound Care Nurse Practitioner verified that she attempted to assess Resident #1's wounds on 4/21/26 but the resident refused to allow her to. The Wound Care Nurse Practitioner stated she was unaware the facility had not obtained treatment orders and agreed that basic treatment orders to clean and dress the wounds could have been obtained despite the resident's refusal of assessment.During an interview on 6/8/26 at 3:47 PM, Registered Nurse (RN) #1 stated the resident refused wound assessment upon admission and that he notified the Director of Nursing of the refusal. He stated he did not recall whether wound care orders were obtained at that time but agreed wound treatment orders should have been obtained.Interview with the Director of Nursing on 6/8/26 at 4:05 PM, she verified the resident had no wound treatment orders prior to 4/22/26 and agreed wound treatment orders should have been obtained upon admission.During a telephone interview, on 6/8/26 at 4:39 PM, the Treatment Nurse stated Resident #1 initially refused wound assessment but agreed wound treatment orders should have been obtained at the time of admission and acknowledged that failure to obtain treatment orders could result in worsening of wounds.Record review of the admission Record revealed that the facility admitted Resident #1 on 4/17/26 with diagnoses that included Diabetes Mellitus, Chronic Venous Hypertension with Ulcer of the Left Lower Extremity, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and Schizophrenia.

Based on observations, resident and staff interviews, record review, and a review of facility policy, the facility failed to honor residents' rights by secluding two (2) of twenty (20) residents in a locked Memory Care unit without proper assessment. This practice violated the residents' right to be free from involuntary seclusion. Resident #23 and Resident #83Findings Include: Review of the facility policy titled, Abuse Component Plan, with an effective date of 10/24/22, revealed under policy, Residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion. Resident #23 An observation and interview on 01/05/2026 at 11:50 AM with Resident #23 revealed him sitting up in chair watching television in his room. His room was located on the back side of the north hall and was behind locked double doors. Resident #23 revealed that he moved to that room recently because he was acting a fool on the other hall. He revealed that they threw him back here so they wouldn't have to deal with him anymore. Resident #23 revealed that he was begging for snacks on the other hall, and they got mad about it and he stated, they put me back here. He also revealed that he was trying to stay out of trouble now. Resident #23 revealed that back here, the doors were locked, and he couldn't get out without asking someone. An interview on 01/05/26 at 12:25 PM with Registered Nurse (RN) #1, revealed that Resident # 23 was in the Memory Unit. She revealed that residents with behaviors, residents who wandered in and out of other resident rooms and those who needed close monitoring were placed behind locked doors. She revealed that they allowed residents to come out if they wanted to, but that the staff had to put in a code to unlock the doors to let them out. RN #1 revealed that some of the residents back in the unit were really confused and required close monitoring. She revealed that Resident #23 was in his right mind and had been back there for a short time. She revealed that he was previously on the South Hall but was transferred back to the Memory Unit because of his behaviors. RN #1 revealed that Resident #23 was constantly stealing snacks out of the refrigerator behind the nursing desk on the South Hall, following the staff around, begging for more snacks, money, and talking over them. RN #1 revealed that Resident #23 was getting on their nerves on the South Hall and they moved him to the North Hall, and they could monitor him more closely behind these locked doors. An interview on 01/06/26 at 3:00 PM with Assistant Director of Nursing (ADON), revealed that they had residents with dementia and those with psychiatric issues in rooms behind the locked doors. She revealed that Resident #23 had only been back there behind locked doors for about a week. She revealed that he was transferred down to this hall from the South Hall due to his behaviors. She revealed that he was constantly asking staff and residents for money, he was going into the refrigerator at the nursing desk and getting snacks. ADON revealed that Resident #23 told her that he felt like they threw him back there so they wouldn't have to deal with him anymore and agreed that it was like they punished him for bad behavior. She also acknowledged that by secluding residents involuntarily could cause increase in behaviors especially in the more cognitive residents. She confirmed that the resident did not have a psychiatric evaluation or any other services prior to moving the resident to the locked unit. An interview on 01/06/26 at 3:08 PM with Licensed Practical Nurse (LPN) #2, revealed that she was familiar with Resident #23. She revealed that he was on the South Hall before he transferred to the North Hall. She revealed that Resident #23 would go behind the nursing desk on the South Hall and get snacks out of the refrigerator without permission. She revealed that he asked for money often to get snacks out of the vending machine. She revealed that they would re-direct him and explain to him that he could not help himself to the snacks and he would leave and come right back. She revealed that they reported this to the Administrator and that's why they moved him to the locked unit behind the double doors. Record review of Resident #23's admission Record revealed an admission date of 08/25/21 and that he had diagnoses that included Unspecified Impulse Disorder, Restlessness, and Agitation. Record review of Resident #23's Progress Note dated 01/02/26, revealed that the Social Worker (SW) made contact with the RP (Responsible Party) over the phone. SW expressed that the Resident was going to have a room change due to his recent behaviors. RP agreed and stated that were going to come and visit. Record review of Resident #23's Minimal Data Set (MDS) with Assessment Reference Date (ARD) of 11/03/25 under Section C, revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that he had no cognitive deficits. During an interview on 1/05/26 at 12:45 PM, the Administrator confirmed that the facility maintains a locked unit at the end of the North Hall, with men housed on one side and women on the other. The Administrator revealed that the unit has historically been structured this way and is used not only for residents with Alzheimer's disease but also for residents exhibiting behaviors. The Administrator acknowledged awareness that secluding residents in this locked unit infringes upon their right to be free from involuntary seclusion and stated, We have a lot of behaviors at this facility. During an interview on 1/05/26 at 4:00 PM, Certified Nursing Assistant (CNA) # 6 revealed that this unit back here is basically an Alzheimer's unit, but there are a lot of people back here without Alzheimer's that just have behaviors that they can't control out in the main unit. She revealed that we keep the women behind this locked door, and the men are kept on the other side of the locked door. Resident #83 An observation and interview on 1/05/2026 at 4:50 PM revealed that Resident #83 was sitting close to the locked double doors in the women's unit. Resident #83 asked the State Agent (SA) if she would go over to the men's side and buy her two drinks out of the vending machine. Resident #83 revealed she was not allowed outside of the double doors and had to wait and ask someone to go to the drink machine for her. Resident #83 revealed she would like to go get things she wants without having to ask someone to do it for her. Resident #83 stated, I just stay back behind the doors like I'm supposed to, but it would be nice to go outside the doors. Resident #83 retrieved two dollars from inside her boot, and CNA #6 retrieved the drinks for her. CNA #6 stated, We go and get whatever they want, but they don't come out of the locked unit. During an interview on 1/06/2026 at 9:45 AM, the Corporate Nurse revealed that our corporation recently purchased this facility in November 2025, and they had questioned why those residents were behind locked doors, especially since they were not a licensed Alzheimer's unit. The Corporate Nurse confirmed that, without proper assessment, the residents were placed in an involuntary seclusion area of the building. A record review of Resident #83's admission Record revealed the facility admitted the resident on 3/4/19 with diagnoses that included Type 2 Diabetes Mellitus, Schizoaffective Disorder and Peripheral Vascular Disease. A record review of Resident #83's MDS with an ARD of 12/5/25 revealed, under section C, a BIMS score of 14, which indicated the resident is cognitively intact.

Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure a resident's right to dignity, choice, and self-determination by failing to assist one (1) of the twenty-seven sampled residents to attend the facility's beauty shop as requested. Resident #37Findings Include: Review of the facility policy titled, Resident Rights with revision date of December 2016, revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . On 1/5/26 at 11:45 AM, an observation and interview revealed Resident #37 seated in her wheelchair with visibly overgrown hair, measuring approximately four inches of gray overgrowth with red coloring remaining on the bottom half of her hair. Resident #37 revealed she was admitted to the facility in June 2025 and had been requesting assistance to go to the beauty shop since admission. She stated, It's like it falls on deaf ears. No one ever takes me. The resident further stated, I have never had my hair look so terrible. On 1/6/26 at 8:50 AM, a follow up observation revealed no change in the resident's appearance. During an interview on 1/6/26 at 2:25 PM, Certified Nurse Aide (CNA) #1 confirmed that Resident #37 had previously requested to go to the beauty shop. CNA #1 revealed the beautician was only coming a few times a month, and we didn't know when she would be here, so we would just miss her. Now I don't think we have a beautician. CNA #1 confirmed Resident #37 had visibly overgrown hair and revealed she could understand her wanting to go to the beauty shop. In an interview on 1/6/26 at 3:15 PM, the Administrator (ADM) revealed that he was unaware that Resident #37 had requested to go to the beauty shop and had not been assisted in doing so. He revealed if the resident was requesting to go to the beauty shop and was not assisted to do so, then her rights were violated. During an interview on 1/6/2026 at 4:37 PM, the Social Worker (SW) revealed that we were made aware in the latter part of December that the beautician would not be returning. She stated, Once the staff was made aware that we would not have a beautician, the CNAs were informed that they were going to be responsible for doing the residents' hair when they gave them showers, such as putting in pig tails and braiding their hair. She stated, I don't know who will be responsible going forward with cutting the residents' hair, that's above my pay grade. The SW revealed there were usually certain residents who went to the beauty shop, and she is not sure how Resident #37 got missed. During an interview on 1/6/26 at 5:25 PM, with the Director of Nurses (DON) present, Resident #37 stated, For 39 years, I went to the beauty shop every Friday. I have never had my hair looking this bad in all my life. I have been here since last June and have not had my hair cut or styled. This is really important to me, and I have asked about it several times. The DON assured Resident #37 that the matter would be addressed. An interview on 1/6/26 at 5:30 PM, DON revealed she is new to the facility and was unaware that the resident was requesting beauty shop services. The DON revealed it is the facility's expectation that residents' rights would be honored regarding personal grooming, including hair care, and confirmed the facility failed to ensure Resident #37's rights were honored. A record review of Resident #37's admission Record revealed the facility admitted the resident on 6/23/25 with diagnoses that included Polyneuropathy, Major Depressive Disorder, and anxiety disorder. A record review of Resident #37's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/17/25 revealed, under section C, a Brief Interview of Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment.

Based on resident and staff interview, record review and facility policy review the facility failed to ensure residents' grievances regarding missing personal clothing were investigated, resolved, and communicated to the resident for two (2) of 27 sampled residents. Resident #29, and Resident #37. Findings Include:Record review of the facility policy titled Resident Care Grievance Policy with an effective date of 6/26/2023 revealed, Grievance decisions should include the following: .date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance and the date the decision was issued .Resident #29During an interview on 1/05/2026 at 11:45 AM, Resident #29 reported that Unsampled Resident A repeatedly entered her room and removed her clothing from the hangers in her closet. Resident #29 stated she had reported the issue to staff for a long time, yet the problem continued to be unresolved. She further stated she kept her privacy curtain open so she could have a view of her closet to monitor her room and yell if Unsampled Resident A entered.During an interview on 1/06/2026 at 2:30 PM, Certified Nurse Aide (CNA) #1 confirmed that missing clothing was a big problem on this unit and stated the issue was not due to unlabeled clothing but due to Unsampled Resident A, who had dementia and routinely entered other residents' rooms and took their belongings. CNA #1 confirmed that complaints from residents have been reported to nursing staff and the social worker, and that everyone is aware of this problem, but nothing is being done about it.A record review of Resident #29's admission Record revealed the facility admitted the resident on 6/11/24 with diagnoses that included Crohn's Disease, Hemiplegia and Hemiparesis, and Malignant Neoplasm of Colon. A record review of Resident #29's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/25 revealed, under section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #37During an interview on 1/05/2026 at 11:50 AM, Resident #37 revealed that upon admission, she had six pairs of slacks and several shirts and stated that she no longer had any clothing in her closet. She reported repeatedly notifying staff, with no resolution, and further stated, It is so frustrating, I don't know where my clothes are.During a follow-up interview on 1/06/2026 at 8:05 AM, Resident #37 stated she was unable to leave her room due to a lack of clothing. An observation of her closet revealed that no clothing was present, and there were six empty hangers.A record review of Resident #37's admission Record revealed the facility admitted the resident on 6/23/25 with diagnoses that included Polyneuropathy, Major Depressive Disorder, and anxiety disorder. A record review of Resident #37's MDS with an ARD of 12/17/25 revealed, under section C, a BIMS score of 10, indicating moderate cognitive impairment. During an interview and observation on 1/06/2026 at 2:35 PM, Registered Nurse (RN) #1 confirmed that missing clothing was an ongoing issue, stating that staff were aware that Unsampled Resident A removed clothing from residents' rooms and hid it in her wheelchair. Observation revealed Unsampled Resident A seated in the dayroom with a large quantity of clothing concealed in her wheelchair. RN #1 retrieved approximately ten articles of clothing belonging to various residents. RN #1 confirmed staff routinely retrieved clothing and attempted to redirect Unsampled Resident A, but she will resist and fight us. RN #1 revealed our interventions are ineffective, and the missing clothing issue continues daily with no resolution.During an interview on 1/06/2026 at 3:30 PM, the Social Worker confirmed awareness that Unsampled Resident A was taking other residents' clothing and acknowledged that staff were just trying to redirect and return the other residents' clothing. She confirmed no steps had been taken to resolve the issue and that complaints from Residents #29 and #37 remained unresolved.During an interview on 1/07/2026 at 9:14 AM, the Administrator confirmed awareness of Unsampled Resident A's behaviors but stated he was not aware of any specific resident complaints regarding missing clothing. He confirmed that when residents voice complaints, a grievance process should be initiated and further acknowledged that no grievances had been filed for Residents #29 or #37.

Based on observation, staff interviews, record review, and facility policy review, the facility failed to ensure a resident's Minimum Data Set (MDS) was accurately coded for one (1) of twenty-seven (27) MDS assessments reviewed (Resident #105). Findings include:Review of a facility policy titled, Certifying Accuracy of the Resident Assessment, revealed, All personnel who complete any portion of the Resident Assessment must sign and certify the accuracy of the portion of the assessment .An observation on 1/05/26 at 11:30 AM revealed the resident's bilateral hands appeared contracted in appearance.Review of Section GG0115, Functional Limitation in Range of Motion (ROM), of the Quarterly MDS dated [DATE] revealed the resident was coded as having no impairment to the upper extremities.An interview with the Director of Nursing (DON) on 1/06/26 at 3:00 PM revealed she stated she had observed the resident's contracted hands and that the resident was supposed to have splints applied to his hands. She further stated that upon review of the resident's record, MDS Section GG had been coded incorrectly, as it was coded to reflect no impairment of the upper extremities despite the resident having bilateral hand contractures. She stated accurate MDS coding is required to provide an accurate depiction of the resident's functional status.Review of the admission Record revealed Resident #105 was admitted on [DATE] with diagnoses including type 2 diabetes and contracture of the right hand.Review of the Brief Interview for Mental Status (BIMS) for Resident #105 dated 11/20/25 revealed a score of nine (9), indicating the resident was moderately cognitively impaired.

Based on observation, staff and resident interview, record review, and facility policy review, the facility failed to develop a communication care plan for (Resident #46), failed to implement a Behavioral care plan for (Resident #22), failed to implement an activities of daily living (ADL) care plan for (Resident #29, #64, and #105), and failed to implement a range of motion (ROM) care plan for (Resident # 105) for six (6) of 27 care plans reviewed.Findings include: Review of the facility policy titled, Care Plans, Comprehensive Person Centered, last revised March 2022, revealed the policy statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Resident #22 Review of the Behavior Management care plan, last revised 12/06/25, revealed the intervention: 1 on 1 (one-on-one) precautions. During an observation and interview with Resident #22 on 1/05/2026 at 11:40 AM, the resident stated he wanted to go back to where he came from, and this conversation with the resident continued for approximately five minutes. When asked if the gentleman asleep in a chair in his room was his family member, Resident #22 stated, No, he is supposed to be watching me but just look at him sleeping. The gentleman asleep in the chair did not awaken during the observation and interview. During the continued observation and interview on 1/05/26 at 11:48 AM, Certified Nurse Assistant (CNA) #3 stepped into the room and she identified the gentleman asleep in the chair as the Transporter assigned to sit with Resident #22 due to one-on-one supervision related to the resident's behaviors. The CNA loudly called the Transporter's name three times, and he did not awaken. An interview with the Minimum Data Set (MDS) nurse on 1/06/26 at 2:50 PM she stated that upon review of the resident's Behavior Management care plan, staff did not implement the one-on-one supervision when the assigned staff member was observed sleeping in the room and not observing the resident. She stated the purpose of the care plan is to direct the specific care each individual resident requires. Record review of the admission Record revealed Resident #22 was admitted on [DATE] with diagnoses including paranoid schizophrenia and bipolar disorder. Record review of the Brief Interview for Mental Status (BIMS) for Resident #22 dated 12/12/25 revealed a score of 15, indicating the resident was cognitively intact. Resident #29 Resident #29's Care plan revealed, I require assistance with my adls related to my history of cerebrovascular accident (cva) with left sided weakness/hemiplegia, right hand contracture, incontinent bowel/bladder, diagnosis of liver and colon cancer along with my history of Crohn's disease with small bowel obstruction. Under approaches: Shower every other day and PRN (as needed). On 1/05/2026 at 11:30 AM, an observation and interview revealed that Resident #29 was lying in bed, with her hair disheveled, and was wearing a white gown with dried liquid in various circles, visible on her gown. The resident revealed that she is supposed to get a shower each Tuesday, Thursday, and Saturday. She confirmed that she did not get a shower on Saturday and was not offered one. She revealed that the last time I had a shower was last Thursday, and that was the last time I had my clothes changed, so I have been wearing the same outfit for four (4) days. The resident revealed she had not had her hair combed since two days before Thanksgiving. In an interview and observation on 1/06/2026 at 11:05 AM, CNA #1 confirmed the resident's hair was disheveled and unkempt. On 1/06/2026 at 5:15 PM, during an interview and observation with the Director of Nurses (DON) present, Resident #29 reiterated her hair had not been combed since two days before Thanksgiving. The resident's hair remains disheveled and unkempt. The DON confirmed that the resident's hair needed attention and that she would ensure it was addressed. The DON revealed that each of our residents should always be adequately groomed and presentable, and with Resident #29 not adequately showered and her hair not attended to, then her plan of care was not being followed. An interview on 1/7/26 at 4:10 PM the MDS nurse revealed according to Resident #28's care plan she is supposed to receive a shower every other day and as needed. She revealed if her last shower was last Thursday then her plan of care was not being followed. She revealed hair care falls under the approach of having a shower. She revealed that the staff know that when a resident has a shower, they should also have their hair brushed. She confirmed that the resident's care plan was not implemented and revealed that we could do a better job by being more specific in developing each resident's individual plan of care. A record review of Resident #29's admission Record revealed the facility admitted the resident on 6/11/24 with diagnoses that included Crohn's Disease, Hemiplegia and Hemiparesis, and Malignant Neoplasm of Colon. A record review of Resident #29's MDS with an ARD of 11/14/26 revealed, under section C, a BIMS score of 15, which indicated the resident is cognitively intact. Resident #46 An observation and attempted interview with Resident #46 on 1/06/26 at 8:32 AM revealed he was lying in bed and unable to communicate. He shook his head back and forth as if he did not understand the questions. The resident's roommate verbalized that Resident #46 did not speak English. Record review of Resident #46's Care Plan Report revealed a care plan was not developed for his language/communication barrier. An interview with the MDS Nurse on 1/07/26 at 11:07 AM revealed the purpose of a care plan was for staff to know how to care for the residents. She stated Resident #46 used a phone as a translator to communicate with staff and confirmed a care plan was not developed because they were behind. Record review of the admission Record revealed the facility admitted Resident #46 on 12/11/25 with a diagnosis of Insomnia. Record review of the MDS with an ARD of 12/18/25 revealed under section A1110, What is your preferred language? Spanish was indicated. Section C revealed a BIMS summary score of 15, which indicated Resident #46 was cognitively intact. Resident #64 Record review of the resident's Care Plan identified that he required assistance with ADLs, with approaches including oral care daily and as needed (PRN). An observation and interview conducted on 01/05/2026 at 11:00 AM and 01/06/2026 at 4:35 PM revealed that Resident #64 was observed lying in bed receiving nutrition through a Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident revealed he was unable to take anything by mouth due to difficulty swallowing. Upon observation, the resident's lower teeth exhibited a yellowish-tan substance along the gum line and between the teeth. Resident #64 revealed that staff did not brush his teeth. He stated he would feel cleaner if his teeth were brushed and stated that staff didn't have time, but they need to take time to do it. An observation and interview conducted on 01/06/2026 at 4:50 PM with the DON confirmed that Resident #64's teeth were visibly dirty and needed brushing. The DON stated that CNAs were responsible for providing oral care and that this intervention was included in the resident's care plan. The DON further stated that failure to provide appropriate oral hygiene could result in tooth decay, mouth sores, foul odors, and possible infection, and indicated that staff would address the issue immediately. She also confirmed that by not receiving the proper mouth care, his care plan was not followed. Record review of the admission Record indicated that Resident #64 was admitted on [DATE] with diagnoses including Dysphagia, Hemiplegia, and Hemiparesis. Record review of the MDS with an ARD of 12/23/2025 showed a BIMS score of 9, indicating moderate cognitive impairment. Under Section GG, the MDS documented that the resident was dependent on staff for oral hygiene. Resident #105 Review of a care plan for Resident #105 titled, Resident is at risk for ADLs related to decreased mobility, muscle weakness, and type two diabetes, revealed the following approaches: Nail care per nurse and ROM to upper and lower extremities with AM and PM care. During an observation on 1/05/26 at 11:30 AM revealed the resident's bilateral hands appeared contracted in appearance with no positioning devices in place, and the resident's fingernails were approximately one inch in length. During an observation of Resident #105's hands with CNA #2 on 1/06/26 at 2:18 PM, he confirmed the resident's bilateral hands were contracted and that the fingernails were very long and needed to be trimmed. He confirmed he did not perform any type of range of motion (ROM) to the resident's hands due to the severity of the contractures and stated the nurses were responsible for trimming the resident's fingernails. An interview with the MDS nurse on 1/06/26 at 3:10 PM revealed she stated that if staff failed to trim the resident's fingernails or provide ROM services as outlined, staff failed to implement the resident's care plan as instructed. She stated the purpose of the care plan is to direct resident-specific care for each individual resident. Record review of the admission Record revealed Resident #105 was admitted on [DATE] with diagnoses including type two diabetes and contracture of the right hand. Record review of the BIMS for Resident #105 dated 11/20/25 revealed a score of 9, indicating the resident was moderately cognitively impaired.

Based on observations, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for three (3) of 113 residents residing in the facility. Resident # 29, #64, and # 105 Findings Include: Review of the facility policy titled, ADLs Supporting undated, revealed .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene . Review of the facility policy titled, Fingernail Care, Foot Care, and Podiatry Referral, effective date 4/18/2017, revealed the stated purpose was to provide guidelines for the delivery of safe, evidence-based nail and foot care which promote good personal hygiene, prevent hand, foot, and nail infections, soft tissue injury, and foot ulcers . Resident #29 An observation and interview on 1/05/2026 at 11:30 AM revealed that Resident #29 was lying in bed, with her hair disheveled, and was wearing a white gown with dried liquid in various circles, visible on her gown. The resident revealed that she is supposed to get a shower each Tuesday, Thursday, and Saturday. She confirmed that she did not get a shower on Saturday and was not offered one. She revealed that the last time I had a shower was last Thursday, and that was the last time I had my clothes changed, so I have been wearing the same outfit for four (4) days. The resident revealed she had not had her hair combed since two days before Thanksgiving. During an observation and interview on 1/06/2026 at 8:28 AM, Resident #29 was again observed lying in bed with disheveled hair and unchanged appearance from the previous day, wearing the same gown. The resident stated, Today is Tuesday, so I'm supposed to get my shower today. In an interview and observation on 1/06/2026 at 11:05 AM, with Certified Nursing Assistant (CNA) #1 confirmed that the resident gets her showers on Tuesday, Thursday and Saturday and stated, The resident does not refuse care. CNA #1 revealed I'm not sure what happened with her not getting a shower this past weekend, but she is supposed to get a shower today. She confirmed the resident's hair was disheveled and unkempt. Observation and interview on 1/06/2026 at 3:10 PM revealed Resident #29's clothing had changed; however, her hair remained disheveled and unkempt. Resident #29 revealed, I got my shower today, but the girl didn't comb my hair. She said she doesn't know how to braid my hair. During an interview and observation on 1/06/2026 at 5:15 PM, with the Director of Nurses (DON) present, Resident #29 reiterated her hair had not been combed since two days before Thanksgiving. The resident's hair remains disheveled and unkempt. The DON confirmed that the resident's hair required attention and that she would ensure it was taken care of. The DON revealed that each of our residents should always be adequately groomed and presentable. A record review of Resident #29's admission Record revealed the facility admitted the resident on 6/11/24 with diagnoses that included Crohn's Disease, Hemiplegia and Hemiparesis, and Malignant Neoplasm of Colon. A record review of Resident #29's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/14/25 revealed, under section C, a Brief Interview of Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #64 Review of the facility policy titled Mouth Care, revised February 2018, indicated that The purposes of this procedure are to keep the resident's lips and oral tissue moist, to cleanse and freshen the resident's mouth, and to prevent oral infection . Observations and interviews conducted on 01/05/2026 at 11:00 AM and on 01/06/2026 at 4:35 PM revealed Resident #64 lying in bed and receiving nutrition through his Percutaneous Endoscopic Gastrostomy (PEG) tube. The resident stated that he was unable to take anything by mouth due to difficulty swallowing. Observation revealed a yellowish-tan substance present along the lower gum line and between each tooth. Resident #64 stated that staff did not brush his teeth or keep his mouth clean and reported that he would feel better and cleaner if his teeth were brushed. He further stated that staff didn't have time, but they needed to take time to provide this care. During an observation and interview on 01/06/2026 at 4:40 PM, Licensed Practical Nurse (LPN) #4 confirmed the presence of a yellowish-tan substance along Resident #64's lower gum line and between his teeth. LPN #4 stated that mouth care was to be completed every shift and that failure to provide oral care could result in tooth decay, pain, gingivitis, and possible infection. An observation and interview on 01/06/2026 at 4:50 PM with the DON confirmed that Resident #64's teeth were visibly soiled and required brushing. DON stated that CNAs were responsible for providing mouth care every shift. DON further stated that failure to provide appropriate mouth care could result in tooth decay, mouth sores, foul odors, and possible infection and stated that staff would address the issue. An interview conducted on 01/07/2026 at 10:37 AM with CNA #5 revealed that she had provided care for Resident #64 the previous day. CNA #5 stated that mouth care was expected to be completed every shift but confirmed that she did not brush the resident's teeth. She stated that providing mouth care was difficult due to the resident's PEG tube feeding and the need for the resident to remain upright during that time. CNA #5 further stated that she would want her own teeth brushed daily and agreed that Resident #64 should have his teeth cleaned as well. Record review of the admission Record indicated that Resident #64 was admitted on [DATE] with diagnoses including dysphagia, hemiplegia, and hemiparesis. Record review of the MDS with an ARD of 12/23/2025 revealed a BIMS score of 9, indicating moderate cognitive impairment. Section GG indicated that Resident #64 was dependent on staff for oral hygiene. Resident #105 An observation on 1/05/26 at 11:30 AM revealed Resident #105's bilateral hands appeared contracted in appearance, and his fingernails were approximately one inch in length. An observation on 1/05/26 at 3:00 PM revealed Resident #105's fingernails remained approximately one inch in length. An observation of Resident #105's hands with CNA #2 on 1/06/26 at 2:18 PM revealed he confirmed the resident's fingernails were very long and needed to be trimmed. He stated the nurses are responsible for trimming residents' nails. Upon continued observation of the resident's right hand, it was observed that the first and second fingernails were digging into the resident's palm. CNA #2 stated that untrimmed fingernails could lead to skin breakdown. An observation of Resident #105's fingernails with LPN #1 on 1/06/26 at 2:35 PM revealed he confirmed the resident's fingernails were long, bent inward toward the palm of the hand, and needed to be trimmed. He stated the nurses are responsible for trimming the resident's fingernails due to the resident being diabetic. An interview with the DON on 1/06/26 at 3:00 PM revealed she had observed the resident's contracted hands and that the fingernails on the right hand were digging into the palm and required trimming. She stated failure to provide nail care services could result in worsening skin breakdown and accidents. Record review of the admission Record revealed Resident #105 was admitted on [DATE] with diagnoses including type 2 diabetes and contracture of the right hand. Record review of the BIMS for Resident #105 dated 11/20/25 revealed a score of 9, indicating the resident was moderately cognitively impaired.

Based on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide Range of Motion (ROM) services for (2) two of 60 residents who have limited ROM. (Resident #24 and #105) Findings include: Review of the facility policy titled, Resident Mobility and Range of Motion, with no revision date, revealed the policy statement: Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion . Resident #24 An observation and interview on 01/05/2026 at 11:17 AM with Resident #24, revealed him sitting up in his wheelchair in his room. He had contractures to the second, third, fourth, and fifth digits on his left hand. His fingers were stiff and bent inward, and his fingernails were touching the palm of his hand. Resident #24 stated he had a brace that he wore sometimes, and it was located in the top drawer of his dresser. Resident #24 revealed that the last time he had therapy, the Certified Occupational Therapy Assistant (COTA) told him to let the nurses or aides help him put the brace on. He also revealed that sometimes he had a hard time applying the brace because part of it would fold up and due to his limited use of his hand, he had problems with it. Resident #24 revealed that not everyone knew how to put the brace on and sometimes he didn't get to wear it. He also confirmed that the nurses nor aides offered to put his hand splint on, and he had to go to them and ask for them to put it on him. He confirmed that now since his fingers are touching his palm of his hand that it is harder to get the splint on by himself and he needs help. An interview on 01/06/26 at 3:41 PM with Registered Nurse (RN) #1, revealed that Resident #24 was somewhat independent and liked to do what he could for himself. She revealed that he had a hand splint and the therapy department trained them on how to apply it when he was discharged from therapy. RN #1 revealed that Resident #24 knew he was supposed to ask for help getting it on, sometimes he did, and sometimes he didn't and stated, It was nothing he had to wear every day. RN #1 confirmed that the nurses did not make sure Resident #24 applied the brace as recommended, but they helped him if he asked. An interview on 01/07/26 at 12:03 PM with Director of Nursing (DON), confirmed that there was no order for the use of a hand splint for Resident #24. She agreed that a nurse should have been monitoring, assisting the resident with the splint and ensuring the brace was applied as recommended to prevent worsening of the contracture. She revealed that she did not know how this got missed. An interview on 01/07/26 at 2:41 PM with the COTA, revealed that Resident #24 had therapy for his left-hand contracture about a year ago. She revealed that he had a resting hand splint that the staff were trained on how to apply when Resident #24 was discharged . She revealed that he could apply the hand splint sometimes himself. She revealed that when they discharged him from therapy, they educated the nursing staff and CNAs (Certified Nursing Assistants) on how to apply the resting hand splint, and they took it over. She revealed that the purpose of wearing the hand splint was to prevent the fingers from tightening back up causing worsening contractures and confirmed that if the resident has not worn the splint consistently then the contracture would worsen. An interview on 01/07/26 at 3:03 PM with Assistant Director of Nursing (ADON), revealed that Resident #24 had a splint in his room and they were trained on how to apply and take off. She revealed that Resident #24 applied his own brace sometimes and sometimes he didn't. She revealed that when Resident #24 was discharged from therapy, COTA came down to them and trained the Certified Nursing Assistants (CNA)s and trained the nurses on how to apply correctly. She revealed that it was the CNAs responsibility to apply and ensure that the splint stays on for the appropriate time and to report to the nurse if there were any problems. The ADON revealed that she knew there was no order for the hand splint to be applied and stated, This is a learning experience, and we as a whole dropped the ball and will have to fix it. The ADON revealed that they had new staff in and out and she would have COTA to train all staff again on the floor now so that the splint was applied properly. She also confirmed that the nurses were supposed to oversee the CNAs and ensure the splint was applied according to therapy recommendations. Record review of Resident #24's OT (Occupational Therapy) Discharge summary dated [DATE] revealed under Discharge Recommendations that he had a left resting hand splint. Therapist has trained staff on self-range of motion exercises using Right upper extremity to perform Left Upper Extremity Passive Range of Motion exercises and on splint wear to apply three times a week for two to four hours to maintain good Range of Motion and decrease further risk for contracture. Dates of service 12/05/24-01/24/25; Prognosis to maintain Current Level of Functioning (CLOF)= Good with consistent staff follow through Record review of Resident #24's Order Summary Report and his Visual/Bedside Kardex Report documented no orders to apply his hand splint. Record review of Resident #24's admission Record revealed an admission date of 02/21/24 and that he had diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side and Unspecified Pain. Record review of Resident #24's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/03/25 under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 15 which indicated that he had no cognitive deficits. Record review of Resident #24's MDS with ARD of 10/03/25 under Section GG revealed under Functional Limitation in Range of Motion that he had upper extremity impairment on one side. Resident #105 An observation on 1/05/26 at 11:30 AM revealed the resident's bilateral hands appeared contracted in appearance, with no positioning devices in place. An observation on 1/05/26 at 3:00 PM revealed the resident's hands remained in a contracted position. An observation of Resident #105's hands with CNA #2 on 1/06/26 at 2:18 PM revealed he confirmed the resident's bilateral hands were contracted, with the right hand more severely affected. Upon continued observation of the right hand, it was observed that the first and second fingernails were digging into the resident's palm. CNA #2 stated he frequently provided care to the resident and confirmed he did not perform range of motion exercises to the resident's hands due to the severity of the contractures. He further revealed splinting devices were present in the resident's dresser drawer and stated restorative services were responsible for applying the splints; however, the splints had not been applied for approximately two days. He stated failure to provide range of motion and apply splints could result in worsening of the resident's contractures. An observation of Resident #105's hands with Licensed Practical Nurse (LPN) #1 on 1/06/26 at 2:35 PM revealed he confirmed the resident's bilateral hands were contracted and his fingernails were long and bent inward toward the palms of the hands and the resident did not have a splint on his hands. An interview with the DON on 1/06/26 at 3:00 PM revealed she stated she had observed the resident's contracted hands and that the fingernails on the right hand were digging into the palm. She stated the resident was supposed to have splints applied to his hands. She further stated failure to provide range of motion services and apply splints could result in worsening contractures. The DON confirmed the facility did not have restorative services at that time and stated she was unable to locate documentation in the resident's record related to range of motion services or application of splints. Record review of an Occupational Therapy Discharge Summary for Resident #105 dated 3/05/25 revealed the resident had a right wrist-hand-finger orthosis (WHFO) to promote wrist extension, digit extension, and thumb abduction to prevent further risk for joint contracture. The summary further revealed therapy staff had trained facility staff on the resident's restorative program, including splint wear, hand hygiene, and passive range of motion. An interview with the COTA on 1/07/26 at 11:00 AM revealed she stated the resident should wear hand positioning devices daily and receive passive range of motion. She stated she was unaware of when or why the facility stopped applying the devices but confirmed the resident required them to aid in prevention of worsening contractures. Record review of the admission Record revealed Resident #105 was admitted on [DATE] with diagnoses including type two diabetes and contracture of the right hand. Record review of the BIMS for Resident #105 dated 11/20/25 revealed a score of 9, indicating the resident was moderately cognitively impaired.

Based on observation, staff interviews, and record review, the facility failed to provide adequate supervision to prevent accidents for one (1) of twenty-seven (27) residents on the sample (Resident #22). Findings include:Review of a facility policy titled, Safety and Supervision of Residents, with no revision date, revealed the policy statement: Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .An observation and interview with Resident #22 on 1/05/2026 at 11:40 AM revealed the resident stated he wanted to go back to where he came from, and the conversation with the resident continued for approximately five minutes. When asked if the gentleman asleep in a chair in the room was his family member, Resident #22 stated, No, he is supposed to be watching me but just look at him sleeping. The gentleman asleep in the chair did not awaken during the observation and interview.During a continued observation and interview on 1/05/26 at 11:48 AM Certified Nurse Assistant (CNA) #3 entered the room and revealed that the gentleman asleep in Resident #22's room was the Transporter assigned to sit with the resident due to one-on-one supervision related to behaviors. The CNA loudly called the Transporter's name three times, and he did not awaken. CNA #3 then went and got the nurse and the State Agency continued to stay in the room.An observation from the doorway of Resident #22's room on 1/05/26 at 11:50 AM revealed the Transporter remained asleep in the chair.An observation on 1/05/26 at 11:52 AM revealed the Transporter was awakened by another staff member who entered Resident #22's room.An interview with the Transporter on 1/05/26 at 11:54 AM revealed he stated he was sitting with the resident and guessed he had dozed off. He stated he knew he was not supposed to sleep while on duty.An interview with Licensed Practical Nurse (LPN) #2 on 1/05/26 at 11:58 AM revealed Resident #22 had been on one-on-one supervision since the end of December due to behaviors, including threats to kill staff and other residents. She stated that while staff were asleep, the resident was not being supervised and could have acted on his threats or experienced worsening behaviors.Record review of the Order Recap Report for Resident #22 revealed an order dated 12/31/25 for one-on-one precautions related to aggressive behaviors for seven days.An interview with the Director of Nursing on 1/07/26 at 9:34 AM revealed she confirmed Resident #22 was on one-on-one supervision related to behaviors. She stated that if staff were asleep and not monitoring the resident as directed, it could have led to increased behaviors.An interview with Social Services Staff #2 on 1/07/26 at 11:00 AM revealed he confirmed Resident #22 was to remain on one-on-one supervision due to behaviors and aggression. He stated the resident would continue on one-on-one supervision until appropriate placement was determined through the court system.Record review of the admission Record revealed Resident #22 was admitted on [DATE] with diagnoses including paranoid schizophrenia and bipolar disorder.Record review of the Brief Interview for Mental Status (BIMS) for Resident #22 dated 12/12/25 revealed a score of 15, indicating the resident was cognitively intact.

Based on observation, staff interview, Payroll Based Journal data, record review and facility policy review the facility failed to provide adequate staffing to provide nursing and related services to meet the residents' needs safely and in a timely manner for one (1) of 28 sampled residents during survey and five (5) of 5 weekends in July 2023. Findings Include. The Administrator (ADM) provided on facility letterhead that the facility does not have a policy on staffing, the facility follows the State Department of Health Licensure regulations. A record review of PBJ Staffing Data Report CASPER Report 1705D FY (Fiscal Year) Quarter 4 2023 (July1-September 30), revealed Excessively Low Weekend Staffing - Triggered. Triggered = Submitted Weekend Staffing data is excessively low. During an observation and interview on 02/12/24 at 01:34 PM revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she is not certified, she stated she has completed her course but is waiting to take her exam and it has been close to four (4) months. She revealed she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift, because of the risk of the resident falling or slipping out of the sling. She stated the resident was so wet and needed changing and she just could not find anyone to help her. An interview on 2/12/24 at 1:38 PM with NA #3 revealed Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1 were sitting at the nurse's station. NA #3 informed them that she had lifted the resident with a total lift and no assistance from another staff member. RN #1 stated, why did you not come get one of us? NA #3 stated she could not find anyone. RN #1 and LPN #2 revealed that the resident needs a two person assist with a total lift to prevent falls. NA #3 admitted that she had been in-serviced on how to use the total lift and knows that she should have waited to get help from another staff member. An interview on 02/14/24 at 9:00 AM, with the Staffing Coordinator confirmed that the number of staff needed daily in the facility for hands on care is determined by the number of residents inside of the facility and the acuity of those residents requiring care. She confirmed that if there are call-ins or shifts and she is unable to fill in, she notifies the Director of Nursing (DON) and then the DON attempts to get additional staff to come in for hands-on care. She stated the DON and ADM are made aware of additional needs on the schedule. An interview on 2/14/24 at 1:30 PM, with Certified Nursing Assistance (CNA) #4 revealed she had been at the facility for years and she is now the restorative aide. She stated that she has never seen it as bad as it is right now with staffing, and we need more CNA's. She stated that they are doing the best they can and sometimes it's all they can do to turn them, clean them, and feed them, so they may not get three baths a week, they may only get two (2). She confirmed that sometimes the aides use the total lifts alone because there are not enough staff to help., She stated we usually know the residents that we can use one person with the total lift and those that would need 2. She revealed the policy states there must be 2 staff members with a total body lift and has been in-serviced on the policy, but to be honest we just do the only thing we can. An interview on 02/14/24 at 2:54 PM with the ADM confirmed that she was not aware that the facility had triggered on the CASPER report for low weekend staffing. She stated that she has not seen a CASPER report and only receives a report from her corporate office. The ADM stated, I don't know how to pull that information, I have never pulled it. An interview on 02/14/24 at 3:00 PM, with the Account Manager for the facility confirmed that she is unaware of how to pull a report to show where the facility triggered for low weekend staffing. The Account Manager stated, We use a system called Smart Link that pulls from the time clock when people clock in and we compare it to the schedule then reconcile with payroll and then we generate that information into the Payroll Based Journal (PBJ) system, but we don't get a message or a notice that the facility triggers for low staffing. A record review of staffing numbers that the facility reported in the Payroll Based Journal (PBJ) revealed that the facility had excessively low staffing for five (5) out of 5 weekends during July 2023. An interview on 02/15/24 at 8:00 AM, with the ADM confirmed that the facility was excessively low on staffing for 5 of 5 weekends in the month of July 2023. The ADM stated, I knew we were low on some of those dates, and we tried to get staff to come in. An interview on 02/15/24 at 8:30 AM, with the DON confirmed that she was unaware of the facility was short on the weekends. She reported that when they don't have enough staff that they are supposed to call additional people in to work and that she doesn't look at the numbers to make sure that there was enough staff in the facility. The DON confirmed that staff are expected to use 2 people with the total body lift and the CNA should have gone to get someone to help her, anyone like a nurse. She stated they offer incentives to the CNA's when we are not fully staffed, but they quit offering incentive to the CNAs about a month ago.

Based on observations, staff and resident interviews, record review and facility policy review, the facility failed to ensure an environment free of accident hazards as evidenced by one staff member using a two-person total body lift to transfer Resident #55 and standing water in a bathroom (Resident's #39 & 46) for three (3) of 28 residents reviewed on sample. Findings Include Review of the typed statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding accident and hazard prevention. Review of the facility policy titled, Invacare Total Lift with a revision date of 8/16 revealed under the Policy .The Invacare Total Lift is used for total lifts and/or to obtain a resident's weight from bed to chair, chair to bed, or from the floor . Resident #55 An observation and interview on 02/12/24 at 01:34 PM, revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she is not certified, and she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift because of the risk of the resident falling or slipping out of the sling. She stated the resident was so wet and needed changing and she just could not find anyone to help her. This interview continued at the nurse's station where we found Licensed Practical Nurse (LPN) #2 and Registered Nurse (RN) #1. NA #3 informed them that she had lifted the resident with a total lift and no assistance from another staff member. RN #1 stated, why did you not come get one of us and NA #3 stated she could not find anyone. RN #1 and LPN #2 revealed that the resident needs a two person assist with a total lift to prevent falls. NA #3 stated that she had been in-serviced on how to use the total lift and knows that she should have just waited to get help from another staff member. An interview on 2/14/24 at 1:30 PM, with Certified Nurse Assistant (CNA) #4 confirmed that sometimes the aides use the total lifts alone because there is not enough staff to help. She stated we usually know the residents that we can use one person with the total lift and those that would need two (2). She stated that the policy is to use two (2)staff members with a total body lift and has been in-serviced. She stated that to be honest we just do the only thing we can. An interview on 2/14/24 at 2:15 PM, with the Administrator revealed that the staff have Pocket Care Guides that tell them what each resident's care needs are and that Resident #55's indicated she needed a two person assist with total lifts. An interview on 2/15/24 at 8:20 AM, with the Director of Nursing (DON) confirmed that staff are expected to use two (2) people with the total body lift and the NA should have gone out and got someone to help her. She confirmed that the aides have a pocket care guide, and she expects them to use it. She confirmed that the staff receive in-services and training regarding using the total body lift on hire and annually. She confirmed that NA #3 was in-serviced on the use of the total body lift. Record review of NA #3 State approved Nurse Aide Training Program (NATP) certificated revealed it was completed on 11/17/23. Record review of the facility in-services revealed the facility had an in-service dated 11/15/23 regarding full body lifts and that noncertified staff were not to use the lift and that was attended by nursing staff including NA #3. Another in-service was completed on 12/9/23 regarding full body lifts, students cannot use lift without a certified CNA and to follow the pocket care guide that was attended by NA #3. Record review revealed NA #3 had received a Competency Evaluation and Assessment Total Lift on 12/9/23 that indicated the staff member demonstrated proper use of the total lift. Review of the Manufacturers General Guidelines for the Total Body Lift indicated under Operating the Lift .The use of one assistant is based on the evaluation of the health care professional for each individual case. Record review of Resident #55's Admission/Readmission Evaluation dated 3/13/23, revealed under Mobility-that the resident needed a two (2) person assist with a full body lift. Record review of Resident #55's Daily Care Guide revealed the resident needed a two (2) person assist with a total mechanical lift for transfers. Record review of Resident #55's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Cerebral Palsy. Record review of Resident #55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact and in Section G that the resident needed a two-person physical assist with transfers. Resident #39 and #46 During an interview and observation on 02/12/24 at 11:06 AM, with Resident's #39 and 46 revealed the resident's bathroom had a puddle of water in the floor approximately two (2) feet wide by two (2) feet wide between the toilet and the sink. An interview with Resident #39 & 46 revealed they both walk independently. When asked if the staff were aware there was a possible leak, Resident #46 stated, yes, they have come in and looked at it, but no one's fixed it. During an observation and interview on 02/13/24 at 10:30 AM, of Resident #39 & 46's bathroom revealed there was still a puddle of water between the toilet and the sink that was approximately two (2) feet wide by two (2) feet long, that extended to the front of the toilet. In an interview on 2/13/24 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 revealed that she has not been notified about a water leak in Residents #39 & 46's room. She confirmed that staff should put a wet floor sign up and notify the staff or maintenance of the issue so it can be fixed. She confirmed that both of those residents walk independently, and it could have been a fall hazard. During an interview on 2/13/24 at 10:55 AM, with the Administrator confirmed that if the staff find a maintenance issue that needs to be fixed then they need to notify a nurse or maintenance. She confirmed that the water in the floor could have been a fall hazard for the residents in that room. Record review of Resident #39's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Recurrent Depressive Disorders. Record review of Resident #39's MDS with an ARD of 1/23/24 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates the resident is cognitively intact and in Section GG that the resident walked independently. Record review of Resident #46's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia, Unspecified Severity with Anxiety. Record review of Resident #46's MDS with an ARD of 2/9/24 revealed in Section C a BIMS score of 6, which indicates the resident is severely cognitively impaired and in Section GG that the resident walked independently.

Based on observation, staff interview, record review and facility policy review the facility failed to implement a care plan for a resident requiring two person assistance utilizing a total lift with transfers for one (1) of 28 resident care plans reviewed. Resident #55 Findings Include: Record review of the facility policy titled Comprehensive Person-Centered Care Plan with a revision date of 3/18 revealed Policy .Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care . Record review of Resident #55's Care Plans revealed a care plan with a problem onset date of 3/13/23, that indicated the resident required assistance with ADL's (Activities of Daily Living) related to resident has diagnosis of Cerebral Palsy with decrease mobility with interventions that included transfer assistance of two (2) staff members with the total mechanical lift. On 02/12/24 at 01:34 PM, an observation and interview revealed Nurse Assistant (NA) #3 had Resident #55 up in the total lift sling hovering over her wheelchair with no other staff member in the resident's room. An interview with NA #3 revealed she knows she is supposed to have a certified or licensed staff member with her when she uses a total lift. An interview on 2/14/24 at 1:30 PM, with Certified Nurse Assistant (CNA) #4 confirmed that Resident #55's care plan indicated the resident needed a two (2) person assist with transfers. She revealed that the staff have pocket care guides which are the residents' care plans. An interview on 2/14/24 at 2:15 PM, with the Administrator confirmed that Resident #55 had a care plan and a pocket care guide that indicated the resident should have two people assisting with the total body lift and since the staff did not use two (2) people then the care plan was not implemented. She revealed the purpose of a care plan and pocket care guide was to provide the information the staff need to care for the residents. An interview on 2/15/24 at 8:20 AM, with the Director of Nursing (DON) confirmed that Resident #55's care plan indicated the need for two persons assist with the total body lift and since NA #3 did not use two (2) people then the care plan was not implemented. Record review of Resident #55's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Cerebral Palsy. Record review of Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/7/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 14, which indicates the resident is cognitively intact and in Section G that the resident needed a two-person physical assist with transfers.

Based on record review and staff interviews the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed timely for one (1) of 28 resident's MDS reviewed. Resident #14 Findings include: Record review of a document, on company letterhead, dated 2/14/24 provided by the Administrator revealed, The facility does not have a policy on MDS completion and scheduling. The facility follows the Resident Assessment Instrument (RAI) manual. A record review of the RAI Version 3.0 Manual, dated October 2023, Chapter 2, Assessments for the RAI page 2-35, 05. Quarterly Assessment, revealed The Quarterly assessment .must be completed at least every 92 days following the previous Omnibus Budget Reconciliation Act (OBRA) assessment of any type . Record review of the Minimum Data Set (MDS) 3.0 Nursing Home (NH) Final Validation Report, dated 2/9/24, revealed that the Quarterly MDS, with an assessment reference date (ARD) of 1/25/24, for Resident #14 was completed late. During an interview with MDS Registered Nurse (MDS RN) on 2/14/24 at 10:25 AM, she stated that the Quarterly MDS for Resident #14 was completed late. She verified that the assessment was greater than 120 days old. In an interview on 2/14/24 at 10:27 AM, the MDS RN and MDS Licensed Practical Nurse (MDS LPN) stated that they had identified on Friday that the assessment was late but at that point there was nothing that could be done. The MDS LPN stated she is responsible for scheduling assessments and that the assessment was just missed. She stated that she thinks she may have gotten this resident mixed up with another resident with the same last name. They stated the purpose for the MDS was to have an assessment of the resident to create the care plan and know how to take care of the resident. Both MDS Nurses agreed that not completing the MDS timely could result in not having an accurate assessment of the resident's needs causing the resident not to receive appropriate care . During an interview with the Administrator on 12/14/24 at 10:35 AM, she verified that the Quarterly MDS for Resident #14 was completed late and agreed it was her expectation that the MDS would be completed on time. A record review of Resident #14's Face Sheet revealed he was admitted to the facility on [DATE], with a diagnosis of Cerebral Palsy. A record review of Resident #14's Quarterly MDS revealed an ARD of 1/25/24 and a completion date of 2/2/24.

Based on observations, staff, and resident interviews the facility failed to correct maintenance issues in a resident bathroom for two (2) of 28 residents sampled. Residents #39 & #46 Findings Include: Review of the written statement on facility letterhead dated 2/14/24 and signed by the Administrator revealed the facility does not have a policy regarding maintenance repairs. An interview and observation on 02/12/24 at 11:06 AM, with Resident's #39 and #46 revealed the residents share a bathroom and the water in the bathroom will not turn on and there is a puddle of water in the floor approximately 2 feet wide by 2 feet wide between the toilet and the sink. Resident #39 & #46 revealed the sink has not worked in a long time and they both walk independently. When asked if the staff were aware their sink did not work and there appeared to be a leak, Resident #46 stated, Yes, they have come in and looked at it, but no one's fixed it. An observation and interview on 02/13/24 at 10:30 AM, of Resident #39 & #46's shared room revealed there was still a puddle of water between the toilet and the sink that was approximately 2 feet wide by 2 feet long, that extended to the front of the toilet. Observation revealed the handle to the faucet was not attached. Resident #46 revealed that he did not know how to put the faucet handle back on. An observation and interview on 2/13/24 at 10:35 AM, with Nurse Aide (NA) #1 confirmed there was water standing in the floor of Residents #39 & #46's bathroom and that they walked independently. She confirmed that the sink handle was loose and could be removed causing the sink not to be able to be turned on and that the puddle of water could have been a fall hazard for the residents. She revealed that she is not the residents NA, but that the staff are supposed to notify nurses or the maintenance man if there is an issue that needs to be repaired. She stated that a wet floor sign needed to be put up also. An observation and interview on 2/13/24 at 10:40 AM, with NA #2 revealed she is Resident #39 & 46's nurse assistant, and she knew there was some sort of water leak in their bathroom, and she had reported it to one of the nurses but was not sure who. She stated, they have come and looked at it but cannot figure out where the leak is coming from. She confirmed the residents sink handle needed to be fixed, because the residents would not know how to reattach the handle on their own. An interview and observation on 2/13/24 at 10:46 AM, with the Maintenance Supervisor revealed he was not aware that Resident #39 & #46's bathroom had a leak that was causing water to stand in the floor or that their sink faucet had come unattached. He stated, Someone just told me about it as I was walking down the hall. He revealed that normally the staff just verbally tell him when something needs to be fixed, there is no form to fill out or computer system for maintenance request. He confirmed there was water standing in the floor in the resident's bathroom and that the sink faucet handle was not permanently attached and needed to be fixed. An interview on 2/13/24 at 10:50 AM, with Licensed Practical Nurse (LPN) #1 revealed that she has not been notified about a water leak or the sink faucet not being attached in Residents #39 & #46's room. She confirmed that staff should put a wet floor sign up and notify the staff or maintenance of the issue so it can be fixed. An interview on 2/13/24 at 10:55 AM, with the Administrator confirmed that if the staff find a maintenance issue that needs to be fixed they should notify a nurse or maintenance. Record review of Resident #39's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Other Recurrent Depressive Disorders. Record review of Resident #39's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/23/24, revealed in Section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates the resident is cognitively intact and in Section GG that the resident walked independently. Record review of Resident #46's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia and Unspecified Severity with Anxiety. Record review of Resident #46's MDS with an ARD of 2/9/24 revealed in Section C a BIMS score of 6, which indicates the resident is severely cognitively impaired and in Section GG that the resident walked independently.

Based on record review, policy/procedure review and interviews, the facility failed to ensure an effective communication process, including how the communication would be documented between the Long-Term Care (LTC) facility and the hospice provider, to ensure that the needs of the resident were addressed and met 24 hours a day for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM. The facility's failure to provide communication with the hospice provider for Resident #1 lead to Resident #1's death and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 8/9/23 when the facility failed to assure and notify hospice of the physician's order for the psychiatric evaluation and discontinuation of the order. The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After review by the SA, the SA extended the survey from 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23. The State Agency identified Immediate Jeopardy at: CFR 483.70(o)(2)(ii)(D)(E)(1)(2) Hospice Services (849)-Scope and Severity of J. The State Agency (SA) notified the facility's Administrator of the IJ on 8/24/23 at 5:15 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ were completed on 9/7/23 and the IJ was removed on 9/8/23. The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity for CFR 483.70(o)(2)(ii)(D)(E)(1)(2) Hospice Services (849) was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Interview on 8/24/23 at 4:00 PM, revealed the administrator stated that the facility does not have a specific policy/procedure for hospice services but does have one for palliative care for residents. Policy/Procedure review of the facility's Palliative Care policy/procedure last reviewed on 1/15 revealed the Definition: Palliative care is defined as measures and treatments provided to offer comfort to the resident, neither hastening nor prolonging the natural process of dying. Record review by the State Agency (SA) of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified. Record review of Resident #1's Physician Orders for August 2023 revealed Do Not Resuscitate (DNR). Record review also revealed a handwritten Physician Telephone Order dated 8/9/23 that read, psychiatric (psych) consult for evaluation/treatment with no time that order was given. Record review further revealed a Physician Telephone Order dated 8/9/23 that read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Review of a printed Physician's Telephone Order dated 8/9/23 with a time of 4:00 PM read to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. An interview with Resident #1's Medical Doctor (MD) on 8/24/23 at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych. The SA interview on 8/24/23 at 12:45 PM, with the Executive Director of the hospice company, revealed that if a resident of a nursing home and a patient of their hospice needed a psychiatric (psych) evaluation that they can have a psych evaluation. She said they were not aware of the psych evaluation being ordered or discontinued. She said anyone they admit, their social worker goes for the first visit within 24 hours of admit. If it was necessary for him to have a psych evaluation, we would cover the cost. No one ever expressed anything at all regarding a psych evaluation. She looked at the nursing home orders for Resident #1 and did not have the handwritten or a printed order for the psych evaluation or the discontinued order for the psych evaluation. She stated Resident #1 never expressed to hospice staff any suicidal ideations. She said the hospice chaplain went and visited him and the hospice social worker went several times. We knew he had verbalized suicidal ideations because the nursing home staff did tell the hospice staff what he said. We were never called to a care plan meeting. I have no handwritten orders at all on Resident #1. If we have a cardiac patient that wants to see their cardiologist, we would actually cover it. An interview with the Administrator on 8/24/23 at 4:10 PM revealed the facility did not communicate with hospice that Resident #1's psych evaluation had been dc'd (discontinued). The adminstrator stated she did not the facility did not communicate with hospice when the facility was decreasing monitoring of the resident from one-on-one observation to every hour observation. The administrator stated she had a telephone meeting with the [NAME] President of sales for the hospice company 8/23/23 before 10:30 AM. The administrator stated we discussed better communication between hospice staff, the Nurse Practitioner, Nurse and nursing home staff and me. The Administrator stated she wanted to know what is going on with the facility's hospice patients. I asked if hospice had a policy on providing psych services if needed and was told they didn't have one. I told the [NAME] President of sales I felt the hospice wasn't communicating with me when there are changes with a hospice resident. SA interview with [NAME] President of Sales for hospice company by phone on 8/24/23 at 4:25 PM, confirmed he did talk with the Administrator about how the facility nurses can better communicate with hospice staff. The SA interview with the Account Executive for hospice company, on 8/24/23 at 4:30 PM revealed that the hospice company does not have a policy/procedure for psych services. Yes, we talked about better communication when a resident is declining. We spoke about having our staff talk with the nursing home's staff. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM *An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. *A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. *On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on 9/8/2023. On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. The SA validated through record review and interviews with the Administrator, DON and SW that for residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm. The SA validated by record review and interviews with the Administrator, DON and SW that an in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19 [TRUNCATED]

Based on record review, policy/procedure review and interviews, the Medical Director failed to coordinate, implement and evaluate the facility's care of one (1) of seven (7) residents, Resident #1, as evidence by Resident #1 committed suicide by hanging himself with the remote control cord of his bed on an exposed pipe in the ceiling of his room [ROOM NUMBER] days after the Medical Director discontinued the Physician Order for a Psychiatric (psych) Evaluation (eval) for suicidal ideations. During the admission process on 8/9/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. An interview with Certified Nursing Assistant (CNA) #1 revealed that she saw Resident #1 on 8/19/23 around 7:36 AM. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM. The Medical Director failed to oversee the medical care and other designated care and services available for Resident #1 after he expressed suicidal ideations on 8/8/23 and committed suicide on 8/19/23 by hanging himself with the remote control of his bed on an exposed pipe in the ceiling of his room. This placed other residents at risk of serious injury, harm, impairment or death. The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After SA review, the SA extended the survey on 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23. The IJ existed at: 42 CFR 483.70(h)(2)(ii) Responsibilities of Medical Director - F841 - Scope/Severity J The SA notified the notified the facility's Administrator of the IJ on 9/7/23 at 12:30 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ were completed on 9/7/23 and the IJ was removed on 9/8/23. The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.70(h)(2)(ii) Responsibilities of Medical Director (F841) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility's policy/procedure for MEDICAL DIRECTOR last revised 1/16 revealed the PURPOSE: To ensure the presence of a Medical Director to coordinate medical care and to be responsible for implementation of resident care policies, in compliance with applicable regulations. Record review of Resident #1's face sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified. Record review of a handwritten physician order Physician Telephone Order dated 8/9/23 read psychiatric consult for evaluation/treatment with no time that order was given and review of Physician Telephone Order dated 8/9/23 read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Both of these orders were signed by the Resident's physician who is also the Medical Director but did not have a date of the signature. Record review of the printed Physician's Telephone Order dated 8/9/23 with a time of 4:00 PM revealed to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. There were no printed orders for either the psychiatric evaluation on 8/9/23 or the discontinuation of the psychiatric evaluation on 8/9/23. Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on 8/9/23 revealed the administrator, who is also a Registered Nurse, wrote the order to discontinue the psych evaluation. Interview with the Administrator, 8/24/23 at 4:10 PM regarding the discontinued psychiatric (psych) evaluation order on 8/9/23 revealed He (Resident #1) went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He (Resident #1) knew he had a psych evaluation ordered and was (one) 1 on 1 due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood. Interview with Resident #1's physician, who is also the Facility Medical Director on 8/24/23 at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych. The Medical Director went on to say that I didn't know the psych eval had been dc'd (discontinued) until this past Tuesday. The Tuesday referenced by the Medical Director was 8/22/23 which was three (3) days following the death of the resident. A follow-up interview with the Facility Medical Director on 8/24/23 at 1:05 PM confirmed he was unaware of the psychiatric evaluation being discontinued until 8/22/23. The Medical Director stated, I sign hundreds of things when I visit on Tuesdays, and it must have slipped through without me noticing. Record review of the Departmental Notes with a Category: Nursing dated 8/8/21 at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated 8/9/21 at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On 8/19/23 at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR (Pre-Admission Screening and Resident Review) when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions: *The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM. *An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self-reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. *A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident council meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurse's station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. *On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #'1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents' protection, all residents with a history of suicidal ideation were assessed for thoughts of self-harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on 9/8/2023. On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self-reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASRRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident council meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurse's station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #'1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. The SA validated through record review and interviews with the Administrator, DON and SW that for residents' protection, all residents with a history of suicidal ideation were assessed for thoughts of self-harm betwee [TRUNCATED]

Based on record review, policy/procedure review and interviews, the facility failed to be administered effectively and efficiently to provide the mental health care for one (1) of seven (7) residents, Resident #1, as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote control cord from his bed and using an exposed pipe on the ceiling in his room. During the admission process on [DATE], Resident #1 told the admitting nurse that he wanted to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/ On [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM. The facility's failure to be administered efficiently and effectively lead to the death of Resident #1 and placed other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After the SA review, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the physician's order for a psychiatric evaluation for Resident #1 written on [DATE] was discontinued on [DATE]. The IJ existed at: 42 CFR 483.70 Administration F835-Scope and Severity at a J The SA notified the notified the facility's Administrator of the IJ on [DATE] at 12:30 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of at 42 CFR 483.70 Administration F835 was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: Record review of the facility's Job Description for the Administrator/Executive Director dated ,d+[DATE] revealed General Description The Executive Director leads and directs the overall operation of the Facility in accordance with resident needs, government regulations and Facility policies so as to maintain quality care for the residents while achieving the Facility's business objectives. The Job Description for the Executive Director revealed Essential Duties 13. Demonstrates knowledge of all State Department of Health rules and regulations and provides adequate instruction regarding such rules and regulations to appropriate staff. The Job Description revealed Standard Requirements 6. Immediately reports incidents of alleged resident abuse or neglect or alleged violations of resident' rights to appropriate authorities. Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised ,d+[DATE] revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting. Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified. Record review of the initial notification to the State Department of Health Licensure and Certification hotline regarding the suicide of Resident #1 on [DATE] revealed the facility reported an attempted suicide on [DATE] at 9:58 am. Interview with the Administrator on [DATE] at 3:10 PM regarding reporting incidents to the State Agency (SA). The Administrator stated I called and left a voicemail reporting a suicide attempt. He died a little after 9:00 AM. He was pronounced here by Emergency Medical Service (EMS). He was found around 8:30 AM and had a pulse. He was a DNR. They did call the ambulance and hospice right after he was found. I did not update the SA office when he died . The sheriff came after the resident was removed from the facility. We notified EMS, Coroner, hospice, and the sheriff. His body is going to the state crime lab. The coroner took the cord with the body. She revealed she was told to report the incident as a suicide attempt by the facility's Regional Nurse Consultant. Interview with Resident #1's Responsible Party on [DATE] at 1:00 PM revealed that she called the police and sheriff department on [DATE] after her brother had committed suicide. Interview with the Director of Nurses (DON) on [DATE] at 2:00 PM revealed No, we didn't call the police after he died . The sheriff officer just showed up here around lunch. His body wasn't even here anymore. The medical examiner had picked him up earlier. Interview with the Administrator, [DATE] at 4:10 PM regarding the discontinued psychiatric evaluation order written by her on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He (Resident #1) knew he had a psychiatric evaluation ordered and was (one) 1 on 1 due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood. Interview with the Administrator on [DATE] at 10:45 AM confirmed that she did not contact the Ombudsman regarding the suicide of Resident #1 until [DATE] at 11:00 AM. Interview with the Administrator on [DATE] at 10:45 AM revealed I didn't report it to the AG office and that she didn't know she had to contact the AG office. Interview with Attorney General Investigator on [DATE] at 10:37 AM revealed the AG office did not receive notification of this suicide from the facility. He stated it was the resident's sister that contacted the AG office on [DATE]. He said the administrator said she didn't know she had to report to the AG office. Record review of Resident #1's Physician Orders for [DATE] revealed Do Not Resuscitate (DNR). Review of the handwritten Physician Telephone Order dated [DATE] read psychiatric consult for evaluation/treatment with no time that order was given. Physician Telephone Order dated [DATE] read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Review of a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM read Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the administrator, who is also a Registered Nurse, wrote the order to discontinue the psych evaluation. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. Record review of the Patient Care Report by the Emergency Medical Services (EMS) that responded to the facility's call for assistance on [DATE] revealed that EMS received notification at 08:52 [DATE] and were at patient 08:59 [DATE]. The NARRATIVE CHIEF COMPLAINT revealed that EMS found Resident #1 Unresponsive, apneic, and pulseless in bed covered up with blankets by staff. CPR not in progress. Staff states that patient is a DNR (Do Not Resuscitate) and wanted to confirm death by EMS, according to staff, patient was last seen alive ,d+[DATE] minutes ago. Resident #1 was found unresponsive, apneic, and pulseless with airway patent, breathing is absent, skin is pale in color, warm to touch and pupils dilated. The Narrative concludes with DOA-no resuscitation, no transport, (name of county) coroner notified and patient's remains left with nursing staff awaiting coroner. The Patient Care Report revealed EMS leave scene 09:11 [DATE]. Record Review of the REPORT OF DEATH INVESTIGATION revealed the death of Resident #1 was confirmed by EMS on [DATE] 9:00, Coroner notified [DATE] 09:30 and View of Body [DATE] 10:05. The report has the Manner of Death is pending autopsy. The reports Probable Cause of Death: 1. Pending Hanging/Strangulation. Record Review of the Reason for Assuming Medical Examiner Jurisdiction, undated with no time revealed Suicide with a check mark and Medical History Cancer has a check mark. The Narrative Summary of Circumstances Surrounding Death revealed Called to (name of long term care facility) to find a 61 y/o W/M lying supine in bed with what appeared to be ligature marks to the front of his neck. The decedent body was cool to touch with no other obvious injuries. The decedent was taken to (Name of local hospital) to hold for autopsy. The cord used was also sent for evident with decedent. There is a diagram of a body with a line drawn across the neck. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM *An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. *A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. *On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, th [TRUNCATED]

Based on policy and procedure review, record review, and staff interviews, the facility failed to provide behavioral health services to address a resident's needs as evidenced by failure to act upon Resident #1's verbalized suicidal ideations which resulted in Resident #1's suicide in the facility for one (1) of seven (7) residents sampled. During the admission process on [DATE], Resident #1 expressed suicidal thoughts when he told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. On [DATE], the facility obtained an physician order for a psychiatric evaluation. On the same day [DATE], the facility obtained a physician order for hospice services and obtained a second physician order to discontinue the psychiatric evaluation. The facility did not notify hospice services of the order for a psychiatric evaluation or the order to D/C (discontinue) the psychiatric evaluation. Record review revealed a physician order dated [DATE], with no time noted, to place Resident #1 on one-on-one monitoring due to suicidal ideation. Resident #1 remained on one-on-one observation through to [DATE] when the facility obtained an order for every hour observations due to improved mood. On [DATE], Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when she opened the door, LPN #1 observed Resident #1 was hanging from an exposed ceiling pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and performed sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. The facility's failure to provide a psychiatric evaluation for Resident #1 placed this resident and other residents in a situation that lead to Resident #1's death and was likely to cause serious injury, harm, impairment, or death of other residents. The situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE] when the facility failed to notify hospice of the physician's order for the psychiatric evaluation and discontinuation of the order. The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After review by the SA, the SA extended the survey from [DATE] through [DATE]. The State Agency identified Immediate Jeopardy at: CFR 483.40 Behavioral health services (F740)-Scope and Severity of J. The SA (State Agency) notified the facility's Administrator of the IJ on [DATE] at 5:15 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ were completed on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ was removed on [DATE], prior to exit. Therefore, the scope and severity for CFR 483.40 Behavioral health services (F740) was lowered from a J to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: On [DATE] a review of the facility's policy/procedure for Behavior Management and Psycho-pharmacological Medications Monitoring Protocol, last revised ,d+[DATE] revealed, Purpose: Residents with behaviors that are displayed routinely, that effect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with the development of a behavior program. Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised ,d+[DATE] revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting. Record review of Resident #1's Face Sheet revealed that he was admitted on [DATE] to the facility with diagnoses including Malignant Neoplasm of Larynx, unspecified, and Depression, unspecified. Record review of Resident #1's Physician Orders for [DATE] revealed an order for psych. (psychiatric) consult for evaluation/treatment with no time provided. A Physician Telephone Order dated [DATE] read to d/c (discontinue) psych consult d/t (due to) admit to hospice with no time provided. Record review also revealed a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. An interview with the Administrator on [DATE] at 4:10 PM, regarding the discontinued psych. evaluation order written on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psychiatric (psych.) evaluation. He knew he had a psych evaluation ordered and was one (1) on 1 due to what he said about jumping off a bridge. We told him we were discontinuing the psych.evaluation because hospice would provide for his needs. He said he understood. No, I didn't contact his Responsible Party (RP). Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the administrator is also a Registered Nurse and wrote the order to discontinue the psych. evaluation. An interview with Resident #1's Medical Doctor (MD) on [DATE] at 8:30 AM, revealed that the psych evaluation was discontinued because hospice won't pay for psych. Interview with LPN #2 on [DATE] at 8:55 AM, revealed that he heard LPN #1 call for help and immediately went to help. He stated that Resident #1 was hanging from a pipe near the ceiling. He stated he cut the cord which was a bed control cord. The cord was removed from around the resident's neck. He stated the resident still felt warm and had a faint pulse for three (3) minutes. He did sternal rubs to see if the resident would respond and there was no response. He said that staff had called the EMS (emergency medical services) and they arrived. The EMS did an EKG and there was no heart activity. Hospice arrived and called the coroner and family. An interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 9:20 AM, revealed that she saw Resident #1 on [DATE] around 7:36 AM. She stated she was walking by his room and saw his door open. She saw him again lying in bed with his legs moving at 8:00 AM. She stated her assignment changed after 8:00 AM and she was no longer his assigned CNA. She stated that a little later she heard a nurse scream. An interview with LPN #1 on [DATE] at 9:58 AM, revealed that she was Resident #1's assigned nurse on [DATE] on the ,d+[DATE] shift. She first saw him at 7:15 AM on [DATE], he was lying in bed with his eyes closed. She went to his room at 8:30 AM to assist with his breakfast. She opened the room door and saw him hanging from an exposed pipe going across his ceiling. She attempted to get him down but was too short and yelled for help. LPN #2 came to help and had his bandage scissors in his pocket. He cut the cord and they laid the resident down. She stated that LPN #2 did sternal rubs. Staff called 911 for an ambulance and hospice. She stated LPN #2 stated he felt a faint pulse. She stated it appeared he stood on the wheelchair (w/c) to get to the pipe. His w/c was close to where he was hanging. She stated he was warm but unresponsive. She stated he had an order to Do Not Resuscitate (DNR) so Cardiopulmonary Resuscitation (CPR) was not started. She stated the Emergency Medical Services (EMS)'s ran an Electrocardiogram (EKG) and found no heart activity. The coroner was called by the hospice staff when they got here. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM *An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. *A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. *On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. The SA validated through interviews with the Administrator and DON and record review that on [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. The SA validated through interviews with the Administrator and DON that The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. The SA validated through interview with the Administrator that the Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. The SA validated through record review and intervie [TRUNCATED]

Based on record review and staff interviews, the facility failed to coordinate a resident review with the Preadmission Screening and Resident Review (PASARR) program under Medicaid by not referring a resident that expressed suicidal ideations on admission for a significant change in status assessment for review by the State Designated Authority for one (1) of seven (7) residents sampled. Resident #1. During the admission process on 8/8/23, Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on 8/9/23, a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On 8/9/23, Resident #1 wanted to be admitted to hospice services. Another MD order was written on 8/9/23 to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to 8/17/23 when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. The facility's failure to submit a significant change in status assessment for review by the State Designated Authority to ensure Resident #1 received the care and services in the most appropriate setting for his needs after he expressed suicidal ideations on admission and during the next shift placed this resident and other residents in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) investigated the death of Resident #1 on 8/22/23 through 8/28/23. After SA review, the SA extended the survey on 9/7/23 through 9/11/23 and the situation was determined to be an Immediate Jeopardy (IJ) when began on 8/9/23 when the physician's order for a psychiatric evaluation for Resident #1 written on 8/9/23 was discontinued on 8/9/23 and the facility failed to refer the resident to the State Designated Authority for evaluation. The IJ existed at: 42 CFR 483.20(e)(2) Coordination of PASARR and Assessments - F644 Scope/Severity J The SA notified the notified the facility's Administrator of the IJ on 9/7/23 at 12:30 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 9/8/23, in which they alleged all corrective actions to remove the IJ was completed on 9/7/23 and the IJ was removed on 9/8/23. The SA validated the Removal Plan on 9/11/23 and determined the IJ was removed on 9/8/23, prior to exit. Therefore, the scope and severity of 42 CFR 483.20(e)(2) Coordination of PASARR and Assessments (F644) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings Include: The Administrator provided a statement on a facility letter head revealing the facility had no policy or procedure addressing the process of completing a PASARR significant change in status assessment. An interview with the Administrator on 8/23/23 at 4:10 PM revealed the facility did not do a change of status PASARR for Resident #1 after he had expressed suicidal ideations. She stated, We don't have a specific policy or procedure for doing the PASARR. Record review of the Screening Questionnaire dated 8/7/23 revealed 19. In the last 3 days, has (formal first name of Resident #1) had any of the following problems .e. Displayed self-injurious behavior? The response is Present but not exhibited in last 3 days . 31. Does (formal first name of Resident #1) have any history of mental illness? Mental illness includes any concerns about emotional wellness that interfere with quality of life or daily functioning. This includes depression, anxiety, psychosis, loss of interest in daily activities, etc. The response is checked Yes. Record review of the State Designated Authority's response to the facility Level 1, admission Pre-Admission Screening (PAS), dated 8/8/23 at 12:48 PM revealed, Resident #1 was appropriate for nursing facility placement. Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, Restlessness and Agitation, unspecified and Depression, unspecified. Record review of Resident #1's PASARR information revealed that there was not a change of status form completed and sent to the State Designated Authority for a reassessment after Resident #1 made suicidal ideation statements on 8/8/23 during his admission to the facility. An interview with the Administrator on 8/28/23 at 10:50 AM revealed the Social Worker was responsible for completing the change of status assessment form for the PASARR. An interview with the Social Worker on 8/28/23 at 10:58 AM confirmed she did not submit a change in status PASARR for Resident #1. The Social Worker stated, Because he (Resident #1) was on hospice, my understanding was I didn't have to submit a change in status form to send to the proper State Designated Authority (proper name). An interview with a staff member at the State Designated Authority on 8/28/23 at 11:10 AM revealed that if a resident is voicing suicidal ideations a change of status assessment should be done, even if the resident was admitted to Hospice. She stated that the two (2) incidents are separate. The regulations are giving guidance that states a change of status assessment does not have to be completed anytime a resident is admitted to Hospice if that is the only change in care. Record review of the Departmental Notes with a Category: Nursing dated 8/8/21 at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated 8/9/21 at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On 8/19/23 at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On 08/09/2023, a psychiatric consult was ordered. The resident was admitted to hospice on 8/9/2023. The psychiatric consult was discontinued on 8/9/2023 by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on 8/8/2023, after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on 8/8/23, Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on 8/8/23, to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on 8/19/23. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on 8/19/2023. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on 8/19/2023. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM *An in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. *A resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. *On 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on 08/19/2023, at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on 08/19/2023. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on 9/8/2023. On 9/11/23, the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on 9/7/2023 at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on 8/19/23. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on 9/7/2023, a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on 9/7/23, at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on 9/7/2023, at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on 9/7/2023 at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on 9/7/2023 at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on 9/7/2023, at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed 9/7/2023, at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on 8/23/2023, by the Administrator/Executive Director. Another PASARR in-service/education was completed on 9/7/23, at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on 9/7/23, at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on 08/31/23, by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on 9/7/23 at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on 08/21/2023, at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on 9/5/2023 at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed 08/21/2023, at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on 8/21/2023, by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on 08/21/2023 and 08/22/2023. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on 08/23/2023, at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On 8/23/2023 a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on 08/23/2023, from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on 08/23/2023 by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on 08/23/2023 at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. The SA validated through interviews with the Administrator and DON and record review that on 08/19/2023, the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. The SA validated through interviews with the Administrator and DON that The State Health Department was notified on 08/19/2023 at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on 08/23/2023 by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. The SA validated through interview with the Administrator that the Sheriff's Department was notified on 08/19/2023, at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on 08/23/2023, at 11:00 AM, by the Executive Director/Administrator. The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on 8/19/2023, at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on 8/19/2023 between 10:00 AM and 12:00 PM, by social services. The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on 8/19/2023, by the DON/IP. The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on 8/19/2023 between 1:00 PM and 2:00 PM, by social services. The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed 08/19/2023, by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. The SA validated through record review and interviews with the Administrator, DON and SW that for residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on 08/19/2023, by social services. No resident reported thoughts of self h [TRUNCATED]

Based on record review, policy/procedure review and interviews, the facility failed to report an injury of unknown origin resulting in a serious bodily injury to law enforcement agencies after the death of one (1) of seven (7) residents sampled, Resident #1 as evidenced by Resident #1's suicide on [DATE]. Resident #1 told the admitting nurse during the admission process on [DATE] that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 wanted to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. He remained on one-on-one observation through to [DATE] when he went to every hour observations. Resident #1 was observed by Licensed Practical Nurse (LPN) #1 at 7:15 AM lying in his bed with his eyes closed. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM. The facility made an initial notification to the State Department of Health Licensure and Certification hotline regarding Resident #1 on [DATE] at 9:58 am that reported an attempted suicide. Resident #1 was pronounced dead at the facility on [DATE] at 9:00 am. Resident #1's Resident Representative (RR) notified the local sheriff department and Attorney General's office of the suicide of Resident #1. The facility did not report to these agencies. The facility's failure to report after the suicide of Resident #1 delayed the investigation of his unusual death in the facility and placed residents in a situation that was likely to cause serious injury, harm, impairment, or death. The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After review by the SA, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on [DATE], when the facility failed to notify the local law enforcement and the State Attorney General Office of the suicide of Resident #1. The IJ and SQC existed at: 42 CFR 483.12(c)(1) Reporting of Alleged Violations - F609 Scope/Severity J The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 12:30 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ and SQC were completed on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of 42 CFR 483.12(c)(1) Reporting of Alleged Violations - F609 was lowered to a D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's policy/procedure for Abuse Prevention last dated ,d+[DATE] revealed REPORTING: Alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency, Adult Protective Services (APS) , and local law enforcement as required). Record review of the initial notification to the State Department of Health Licensure and Certification hotline regarding the suicide of Resident #1 on [DATE] revealed the facility reported an attempted suicide on [DATE] at 9:58 am. An interview with the Administrator on [DATE] at 3:10 PM regarding reporting incidents to the State Agency (SA) revealed, I called and left a voicemail reporting a suicide attempt. He died a little after 9:00 AM. He was pronounced here by Emergency Medical Service (EMS). He was found around 8:30 AM and had a pulse. He was a DNR. They did call the ambulance and hospice right after he was found. She revealed she was told to report the incident as a suicide attempt by the facility's Regional Nurse Consultant. Interview with the local Ombudsman on [DATE] at 2:30 PM, revealed she had not been contacted by the facility regarding a possible suicide. Interview with the Administrator on [DATE] at 10:45 AM, confirms that she did not contact the Ombudsman regarding the suicide of Resident #1. She revealed that the Attorney General (AG) Investigator had been at the facility earlier on [DATE] and interviewed two (2) staff members about Resident #1's suicide. She stated she had not contacted the Attorney General (AG) office about Resident #1's suicide and assumed the SA had. She revealed she did not know she should have contacted the AG office. Interview with Resident #1's Resident Representative (RR), on [DATE] at 1:00 PM, revealed that she called the police and sheriff department on [DATE] after her brother had committed suicide. Interview with the Director of Nurses (DON) on [DATE] at 2:00 PM, revealed that No, we didn't call the police after he died . The sheriff officer showed up here around lunch. His body wasn't here anymore. Interview with the AG Investigator on [DATE] at 10:37 AM, revealed the AG office did not receive notification of this suicide from the facility. He stated the resident's sister contacted the AG office on [DATE]. He said the Administrator said she didn't know she had to report to the AG office. Record review by the State Agency (SA) of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified and Depression, unspecified. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call him friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On [DATE], a new preadmission screening and resident review (PASRR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM *An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. *A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. *On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. The SA validated through interviews with the Administrator, DON and SW and a record review that a grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's an in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. The SA validated through interviews with the Administrator, DON, Medical Director and SW and record review that a second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. The SA validated through interviews with the Administrator and DON and record review that on [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. The SA validated through interviews with the Administrator and DON that The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. The SA validated through interview with the Administrator that the Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. The SA validated through record review and interviews with the Administrator, DON, SW #1 and Medical Director that on [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. The SA validated through record review and interviews with the Administrator, DON and SW that a trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services. The SA validated through record review and interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that all staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP. The SA validated through record review and interviews with the Administrator and DON that all care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services. The SA validated with record review and interviews with the Administrator and DON that 100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3 [TRUNCATED]

Based on record review, policy/procedure review, and interviews, the facility neglected to identify a crisis of suicidal ideation of Resident #1 and neglected to provide the psychiatric services that were necessary to prevent death for one (1) of seven (7) residents sampled as evidenced by Resident #1 committed suicide by hanging on [DATE] using the remote-control cord from his bed and using an exposed pipe on the ceiling in his room. On [DATE], during the admission process Resident #1 told the admitting nurse that he wanted to call a friend to pick him up and take him to jump off a bridge. During the 11:00 PM to 7:00 AM shift, on [DATE], a Medical Doctor's (MD) order was written for a psychiatric (psych) evaluation. On [DATE], Resident #1 elected to be admitted to hospice services. Another MD order was written on [DATE] to discontinue (D/C) the psych evaluation and resident was admitted to contract hospice services. An order was written on [DATE] with no time noted to place Resident #1 on one-on-one monitoring due to suicidal ideation. He remained on one-on-one observation through to [DATE] when the facility reduced the resident's supervision from one-on-one to every hour observation due to improved mood. LPN #1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted to be warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down and began doing sternal rubs with no response. Emergency Medical Services (EMS) were called as were hospice services. EMS arrived to the facility and found Resident #1 with no heart activity and he was pronounced dead at 9:00 AM. The facility's failure to provide psychiatric services including a psych evaluation for Resident #1 placed this resident in a situation that likely led to death and placed other resident in a situation that could likely lead to serious injury, impairment or death. The State Agency (SA) investigated the death of Resident #1 on [DATE] through [DATE]. After SA review, the SA extended the survey on [DATE] through [DATE] and the situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) when began on [DATE] when the physician's order for a psychiatric evaluation for Resident #1 written on [DATE] was discontinued on [DATE]. The IJ and SQC existed at: 42 CFR 483.12 (a)(1)Freedom from Abuse, Neglect, Exploitation- F600 - Scope/Severity J and SQC. The SA notified the facility's Administrator of the IJ and SQC on [DATE] at 12:30 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on [DATE], in which they alleged all corrective actions to remove the IJ and SQC were completed on [DATE] and the IJ was removed on [DATE]. The SA validated the Removal Plan on [DATE] and determined the IJ and SQC was removed on [DATE], prior to exit. Therefore, the scope and severity of 42 CFR 483.12 (a)(1) Freedom from Abuse, Neglect, Exploitation (F600) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Record review of the facility's Abuse Prevention last dated ,d+[DATE] revealed Definition: f) Neglect: A failure of the facility, its employees, or service providers to provide goods and services necessary to avoid physical harm, mental anguish, emotional distress, or pain. Record review of the facility policy Physician Orders history ,d+[DATE] ( A.15) revealed .Procedure .4. The .time of the order must appear . Policy/procedure review of the facility's policy/procedure for Suicide Precautions, last revised ,d+[DATE] revealed .Procedure 8. Undertake emergency transfer of resident to appropriate treatment setting. Record review of Resident #1's Face Sheet revealed he was admitted on [DATE] to the facility with diagnoses which included Malignant Neoplasm of Larynx, unspecified, Restlessness and Agitation and Depression, unspecified. Record review revealed no order for an emergency transfer of Resident #1 to an acute care facility. Record review of Resident #1's Physician Orders for [DATE] revealed Do Not Resuscitate (DNR). The orders also revealed a Handwritten Physician Telephone Order dated [DATE] read psychiatric consult for evaluation/treatment with no time documented that the order was given. Physician Telephone Order dated [DATE] read d/c (discontinue) psychiatric consult d/t (due to) admit to hospice with no time that order was given. Record review revealed a printed Physician's Telephone Order dated [DATE] with a time of 4:00 PM to Admit to hospice (proper name) related to diagnosis of malignant neoplasm of larynx. Record review revealed there were no printed physician orders for a psychiatric consult on [DATE] or to d/c a psychiatric consult on [DATE]. Record review of the MD's (Medical Doctor) order to discontinue the psych evaluation written on [DATE] revealed the Administrator, a Registered Nurse, wrote the order to discontinue the psych. evaluation. Interview with Resident #1's Medical Doctor (MD) on [DATE] at 8:30 AM revealed that the psychiatric evaluation was discontinued because hospice won't pay for psych. He also revealed that he didn't know the psychiatric evaluation had been discontinued until [DATE], which was three days after the suicide. Interview with the Administrator, [DATE] at 4:10 PM, regarding the discontinued psychiatric (psych) evaluation order on [DATE] revealed He went on hospice. That is why the order was discontinued. Hospice won't pay for a psych eval. He knew he had a psych evaluation ordered and was one on one due to what he said about jumping off a bridge. We told him we were dc'ing (discontinuing) the psych evaluation because hospice would provide for his needs. He said he understood. Interview with the Administrator on [DATE] at 10:45 AM revealed LPN #3 did call me on [DATE] and let me know what Resident #1 said during the admission process. She stated she immediately put him one on one and got a psychiatric consult order from the Medical Director, who was the resident's primary physician. On [DATE], Resident #1 wanted to be admitted to hospice. He went on hospice on [DATE]. Hospice isn't going to pay for consults, so the psychiatric consult was discontinued. If a resident is a Do Not Resuscitate (DNR) and on hospice or palliative care only, any consults will be discontinued. The Administrator stated that the decision to send a resident for emergency care would depend on the resident and their specific situation. Interview with Licensed Practical Nurse (LPN)/admitting nurse/Unit Manager on [DATE] at 10:35 AM revealed, It didn't cross my mind to send him out for an emergency evaluation related to the suicidal ideation he had voiced. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 9:31 PM revealed, .Resident stated that he's scared of been in (being) in facility and in room by himself Please don't leave me alone, I'm scared .Resident states he doesn't want to die here .Resident not adjusting to new surroundings well. Resident hollering out loud .Resident refuse to stay in his room due to he's scared of been (being) alone .Stating that he wants to call his friend to pick him up so he can jump off bridge cause he's tired of living . He was placed one on one observation with staff after making that comment. Record review of the Departmental Notes with a Category: Nursing dated [DATE] at 7:21 AM revealed, .Resident constantly states he wants to die. He wrapped oxygen tubing around his neck .Resident asked staff if he hit his head against the wall will go ahead and take him out . On [DATE] at 6:23 AM, Resident #1 ambulated to the nursing station and stated he had slipped. A laceration on his face and skin tear on his arm were cleaned. Resident #1 was observed by Licensed Practical Nurse #1 at 7:15 AM lying in his bed with his eyes closed. LPN#1 took Resident #1's breakfast tray to his room at 8:30 AM and when the door was opened, Resident #1 was observed hanging from a pipe with the bed remote control cord wrapped around his neck. He was noted warm. LPN #1 yelled for help and LPN #2 responded. LPN #2 cut Resident #1 down using bandage scissors and began doing sternal rubs with no response. The facility called Emergency Medical Services (EMS) and hospice services. EMS arrived at the facility and found Resident #1 with no heart activity, and he was pronounced dead at 9:00 AM. Hospice contacted the coroner, and the body was released to the Medical Examiner. An interview with LPN #2 on [DATE] at 8:55 AM, revealed that he heard LPN #1 call for help and immediately went to help. He stated that Resident #1 was hanging from a pipe near the ceiling. He stated he cut the cord which was a bed control cord. The cord was removed from around the resident's neck. He stated the resident still felt warm and had a faint pulse for three (3) minutes. He did sternal rubs to see if the resident would respond and there was no response. He said that staff had called the EMS (emergency medical services) and they arrived. The EMS did an EKG and there was no heart activity. Hospice arrived and called the coroner and family. During an interview with Certified Nursing Assistant (CNA) #1 on [DATE] at 9:20 AM, CNA #1 revealed that she saw Resident #1 on [DATE] around 7:36 AM. She stated she was walking by his room and saw his door open. She saw him again lying in bed with his legs moving at 8:00 AM. She stated her assignment changed after 8:00 AM and she was no longer his assigned CNA. She stated that a little later she heard a nurse scream. During an interview with LPN #1 on [DATE] at 9:58 AM, revealed that she was Resident #1's assigned nurse on [DATE] on the ,d+[DATE] shift. She first saw him at 7:15 AM on [DATE], he was lying in bed with his eyes closed. She went to his room at 8:30 AM to assist with his breakfast. She opened the room door and saw him hanging from an exposed pipe going across his ceiling. She attempted to get him down but was too short and yelled for help. LPN #2 came to help and had his bandage scissors in his pocket. He cut the cord and they laid the resident down. She stated that LPN #2 did sternal rubs. Staff called 911 for an ambulance and hospice. She stated LPN #2 stated he felt a faint pulse. She stated it appeared he stood on the wheelchair (w/c) to get to the pipe. His w/c was close to where he was hanging. She stated he was warm but unresponsive. She stated he had an order to Do Not Resuscitate (DNR) so Cardiopulmonary Resuscitation (CPR) was not started. She stated the Emergency Medical Services (EMS)'s ran an Electrocardiogram (EKG) and found no heart activity. The coroner was called by the hospice staff when they got here. Record review of the Patient Care Report by the Emergency Medical Services (EMS) that responded to the facility's call for assistance on [DATE] revealed that EMS received notification at 08:52 [DATE] and were at patient 08:59 [DATE]. The NARRATIVE CHIEF COMPLAINT revealed that EMS found Resident #1 Unresponsive, apneic, and pulseless in bed covered up with blankets by staff. CPR not in progress. Staff states that patient is a DNR (Do Not Resuscitate) and wanted to confirm death by EMS, according to staff, patient was last seen alive ,d+[DATE] minutes ago. Resident #1 was found unresponsive, apneic, and pulseless with airway patent, breathing is absent, skin is pale in color, warm to touch and pupils dilated. The Narrative concludes with DOA-no resuscitation, no transport, (name of county) coroner notified and patient's remains left with nursing staff awaiting coroner. The Patient Care Report revealed EMS leave scene 09:11 [DATE]. Record Review of the REPORT OF DEATH INVESTIGATION revealed the death of Resident #1 was confirmed by EMS on [DATE] 9:00, Coroner notified [DATE] 09:30 and View of Body [DATE] 10:05. The report has the Manner of Death is pending autopsy. The reports Probable Cause of Death: 1. Pending Hanging/Strangulation. Record Review of the Reason for Assuming Medical Examiner Jurisdiction, undated with no time revealed Suicide with a check mark and Medical History Cancer has a check mark. The Narrative Summary of Circumstances Surrounding Death revealed Called to (name of long term care facility) to find a 61 y/o W/M lying supine in bed with what appeared to be ligature marks to the front of his neck. The decedent body was cool to touch with no other obvious injuries. The decedent was taken to (Name of local hospital) to hold for autopsy. The cord used was also sent for evident with decedent. There is a diagram of a body with a line drawn across the neck. The facility provided the following Removal Plan: Resident #1 was admitted on [DATE]. Resident #1 expressed that he wanted to sign up for hospice services on admission due to him being tired. He stated I been suffering from throat cancer for seven years. I'm just tired. Resident #1 expressed that he wanted to call his friend so that he could jump off a bridge. On [DATE], a psychiatric consult was ordered. The resident was admitted to hospice on [DATE]. The psychiatric consult was discontinued on [DATE] by the physician after he elected hospice services. The facility failed to adequately meet Resident #1's mental health needs when the facility did not provide a psychiatric evaluation on [DATE], after Resident # 1 stated that he wanted to jump off a bridge. The facility failed to ensure the Medical Director evaluated and acted on reported deficient practices related to Resident #1's actual suicide and failed to ensure that orders for the psychological evaluations were carried out as ordered. The facility failed to adequately meet Resident #1's mental health needs when the facility did not complete a status change PASARR when, on [DATE], Resident #1 verbalized suicidal ideations. The facility neglected to provide psychological interventions upon admission, on [DATE], to protect Resident #1, who expressed suicidal ideations and ultimately was found hanging in the facility on [DATE]. The facility failed to accurately report an actual suicide for Resident #1 when he was found hanging from the pipes in the ceiling at 8:15 AM on [DATE]. The incident was reported as an attempted suicide to the department of licensure and certification (L&C) at 9:57 AM on [DATE]. The incident was not reported to the appropriate state agencies within the specific time frame, as required by federal guidance. The Administrator/Executive Director failed to ensure that Resident #1's psychological needs were addressed by a lack of immediate intervention and a lack of carrying out of a physician order for a psychological evaluation, which resulted in Resident #1's death. Interventions * The facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. The Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the activities director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 were in attendance. *On [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. *The facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM *An in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. *An in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. *An in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. *An in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. *An in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. *An in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. *An in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. *A one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. Fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. *A resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. *An education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. *Six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. *A phone meeting was held with the Administrator/Executive Director and the area [NAME] President of Sales for hospice on [DATE], at 9:00 AM, concerning communication and collaboration between hospice and facility to provide better service for the residents receiving hospice care in the nursing facility. On [DATE] a new system change included a hospice communication book was placed at each nurse's station for any change in condition to hospice residents. *A grief counseling meeting was conducted by the hospice Chaplin on [DATE], from 11:00 AM until 3:00 PM for the residents and staff. *An in-service/education was provided to all the licensed nursing staff to notify hospice of all changes in condition, this will include condition changes such as, decline or improvement, medication changes, new orders of any type, and psychiatric needs and/or evaluations. All communication with hospice will be documented in the interdisciplinary notes and placed on hospice notification form (Form #1) in the hospice communication book. The in-service was completed by the DON/IP on [DATE] by 5:30 PM. *A second emergency Quality Assurance meeting held to discuss the new system implemented to communicate with hospice, the new hospice form #1, and communication book. This meeting was held on [DATE] at 5:00 PM. In attendance were the Administrator/Executive Director, the DON/IP, the Unit Manager, Social Worker #1, Social Worker #2 and the Medical Director per phone. *Any employee that has not been in-serviced will not be allowed to return to work until all in-services are completed. *On [DATE], the Emergency Medical Services were notified at 8:51 AM, along with hospice, the coroner, the Department of Health, and the resident's responsible party. *The State Health Department was notified on [DATE] at 9:57 AM, by the Executive Director/Administrator. The Attorney General's Office (AG) was notified on [DATE] by the Executive Director/Administrator at 8:30 AM while at the facility investigating the incident. *The Sheriff's Department was notified on [DATE], at 1:00 PM, while at the facility investigating the incident by the Executive Director/Administrator. The Ombudsman was notified by phone on [DATE], at 11:00 AM, by the Executive Director/Administrator. *On [DATE], at 12:30 PM, an emergency Quality Assurance meeting was held to discuss immediate interventions completed and interventions to be put in place related to Resident #1's suicide. In attendance was the Director of Nursing/Infection Preventionist, the Executive Director/Administrator, the House Supervisor, Social Worker #1, Social Worker #2 and the Medical Director by phone. *A trauma screening was performed on each resident in the facility. No issues were found. This was completed on [DATE] between 10:00 AM and 12:00 PM, by social services. *All staff was in-serviced on abuse, neglect, and suicide precautions starting at 10:00 AM on [DATE], by the DON/IP. *All care plans of residents with a history of suicidal ideation were updated to include the following interventions, residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. *These interventions were added to the plans of care of six residents on [DATE] between 1:00 PM and 2:00 PM, by social services. *100% audit of all beds to ensure bed remote secured to bed by social service, this was completed [DATE], by 3:00 PM. There were two beds that required maintenance to secure the cord to the bed. The cords were secured immediately. *For residents protection, all residents with a history of suicidal ideation were assessed for thoughts of self harm between the hours of 1:00 PM and 3:00 PM on [DATE], by social services. No resident reported thoughts of self harm. *An in-service was provided to social services to ensure that all residents with suicidal ideation will be seen by social service at least weekly, until they no longer have suicidal ideation. This in-service was completed by the DON/IP on [DATE], at 5:00 PM. *An in-service was completed with all staff by the DON/IP at 6:00 PM on [DATE]. Training included that all residents that express feelings of harming themselves will be immediately placed on one on one and seen by the psychiatric nurse practitioner or a physician. If the psychiatric nurse practitioner or the physician are not available, then the resident will be sent to the emergency room for evaluation. Facility alleged compliance on [DATE]. On [DATE], the State Agency (SA) validated the facility's Removal Plan by staff interviews, record reviews, and review of the in-service sign in sheets. The SA verified the facility had implemented the following measures to remove the IJ: The SA validated through interviews and record review that the facility held an emergency meeting on [DATE] at 1:00 PM, with the Quality Assurance team to discuss and implement removal plans for citations F600, F609, F644, F835, F841, related to Resident #1's suicide on [DATE]. Interviews with the Administrator/Executive Director, the DON/IP, the unit manager, the Medical Director, the [NAME] President to the Administrator/Executive Director, social worker #1, and social worker #2 confirmed all were in attendance. The SA validated through record review and interviews with the Administrator/Executive Director, Director of Nurses (DON), Social Worker #1, Social Worker #2 that on [DATE], a new preadmission screening and resident review (PASARR) policy was created for the facility to coincide with federal and state guidelines. The policy was created by the Executive Director/Administrator of the facility and the governing body. The SA validated through record review and interviews with the Administrator/Executive Director, DON, Social Worker #1, Social Worker #2, Medical Director, Unit Manager that the facility implemented the policy for PASARR, to coincide with state and federal regulations. The policy was approved in the Emergency Quality and Assurance meeting held on [DATE], at 1:00 PM. The SA validated through record review and interviews with four Registered Nurses, five Licensed Practical Nurses, eight Certified Nurse Aides, one Laundry staff, three Housekeepers, two Social Workers, one Medical Director, one Administrator/Executive Director that an in-service on neglect and abuse was provided to all staff on [DATE], at 1:30 PM, by the Director of Nursing/Infection Preventionist (DON/IP). The information covered in the in-service included the definition of abuse and neglect, the different types of abuse and neglect, and what steps to take if abuse or neglect is witnessed or suspected. The SA validated through record review and interviews with the Director of Nurses (DON) and Administrator/Executive Director that an in-service education on self reporting requirements was provided to the Administrator/Executive Director and the DON/IP to include reporting accurately to state agencies on [DATE] at 2:00 PM, by the [NAME] President to the Administrator. The abuse and neglect policy was reviewed in the in-service which included the types of incidents that must be reported, the time frame in which to report, and the entities (Attorney General's Office, Licensure and Certification, Ombudsman) that must be reported to. The SA validated through record review and interviews with the Administrator/Executive Director, four RN's and five LPN's that an in-service education was provided with all licensed nurses by the DON on [DATE] at 3:00 PM to review the policy on physician orders including, The signature of the nurse receiving the order and the time of the order must appear. The SA validated through record review and interviews with two Social Workers and Administrator/Executive Director that an in-service education was provided to social service on [DATE], at 3:30 PM, by the Administrator/Executive Director, to include an increase in social visits for all residents with suicidal ideation to be seen by social service at least 3 times weekly, until they no longer have suicidal ideation. The SA validated through interview with the Administrator/Executive Director and record review that an in-service education on the Administrator's job description was provided to the Administrator/Executive Director to include that the Administrator must provide oversight to provide the necessary care for residents who express suicidal ideation and for residents who have psychosocial needs that are not met. This was completed [DATE], at 4:00 PM, by the [NAME] President to the Administrator/Executive Director. The SA validated through record review and interviews with two Social Workers and the Administrator/Executive Director that an in-service education was provided on PASARR to Social Services on [DATE], by the Administrator/Executive Director. Another PASARR in-service/education was completed on [DATE], at 4:30 PM by the [NAME] President to the Administrator, the DON/IP, Social Services, the Medical Director, and the Director of Admission. The information covered in the in-service included when to complete a new PASARR and the appropriate agency to send the completed forms to. The SA validated through record review and interviews with the Medical Director and Administrator/Executive Director that an in-service education on the Medical Director Policy was provided to the Medical Director on [DATE], at 5:00 PM, by the Administrator/Executive Director. The information covered in the in-service included the role and responsibilities of the Medical Director and leading the continuity of care with nursing services to include physician orders with accurate times and dates. The SA validated by record review and interviews with the Administrator/Executive Director and two Social Workers that a one hundred percent audit was completed on [DATE], by the Administrator/Executive Director, of all current resident's PASARRs to ensure status change of assessment has been completed to include new diagnosis and to reflect that mood and behavior changes are included in the status change. The SA validated fifty-eight resident's status change forms were sent to the state mental health authority for a status change on [DATE] at 8:00 PM. The SA validated through interviews with the Administrator, DON and SW #1 and record review a resident council meeting was completed by the activities director on [DATE], at 2:30 PM. The residents were encouraged to express their feelings. An additional follow up resident counsel meeting was held on [DATE] at 2:00 PM by the activities director. No negative effects reported from the residents. The SA validated through interviews with five LPN's, one Activity Director, two Social Workers, one Director of Admissions, three RN's and five CNA's that an education/in-service was provided to social service and nursing staff to immediately get psychiatric evaluation for residents with any new behaviors to include suicidal ideation. This was completed [DATE], at 5:00 PM, by the Administrator/Executive Director and the DON/IP. A memo was placed at each nurses station to reflect the instructions of the in-service completed by 4:00 PM on [DATE], by the DON/IP. The SA validated through interviews with the Administrator, DON and SW and record review that six residents with history of suicide ideation were seen per the psychiatric nurse practitioner, on [DATE] and [DATE]. All residents denied suicidal ideations on evaluation per the psychiatric nurse practitioner. The SA validated through interviews with the Administrator and the [NAME] President of sales for hospice and record review that a phone meeting was held with the Administrator/Executive Director and the area [NAME] Preside [TRUNCATED]

Based on record review, policy review, and staff interviews, the facility failed to report an incident of sexual abuse within the required two hour timeframe, for one (1) of five (5) residents reviewed, Resident #2. On Friday August 28, 2020 at 12:35 AM, a staff member witnessed Resident #1 on top of Resident #2 in her bed. Resident #1 was on top of Resident #2, holding her hands above her head with his left hand, and his right hand (which was not visible) holding his penis and attempting to guide it into Resident #1's vagina, all while making sexually mannered movements with his pelvis. An assessment of Resident #2 was immediately done. Her brief had been torn and pulled to the side, with a small area of blood near the tab of the brief, and another small spot of blood on the front, outside of the brief. There was no outward appearance of injury to her perineal area. A physician's orders [REDACTED].#2 to the hospital to be assessed, and she was found to have a labial abrasion and skin tears to her perineal area and to her vagina consistent with sexual assault. Resident #1 was immediately placed on 1:1 and was subsequently transferred to a Geri-psych unit later that afternoon. The allegation of sexual abuse was called into the State Department of Health by the Director of Nursing (DON) on 08/28/2020 at 4:22 AM, three (3) hours and forty-two (42) minutes after the alleged incident. The facility did not follow established policy and procedure for reporting allegations of resident abuse, neglect and/or exploitation. The failure of the facility to notify the appropriate State agencies in a timely manner of an allegation of abuse, placed residents at risk for the likelihood or serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on 09/11/2020, which began on 08/28/2020 when Resident #1 was witnessed on top of Resident #2 in her bed, attempting to engage in non-consensual sexual activity. The facility failed to notify the appropriate agencies of an alleged incident of sexual abuse, within the required two hour timeframe. The facility ' s Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the IJ on 09/11/2020 at 2:05 PM. The facility submitted a Removal Plan on 09/12/2020 at 3:30 PM, in which the facility alleged all corrective actions to remove the IJ were completed. The State Agency (SA) validated the facility's Removal Plan on 09/14/2020 and determined the IJ was removed on 09/12/2020. Therefore, the scope and severity for CFR(s): 483.12(c)(1) - Reporting of Alleged Violations, (F609) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse Prevention Policy, last revised 11/2017, revealed, the facility is committed to protecting the residents from abuse by anyone. Definitions included: Abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Sexual Abuse - This includes but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. To protect residents, suspected or substantiated cases of resident abuse shall be thoroughly investigated, documented, and reported to the physician, families and/or representatives, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than two (2) hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse is to be reported to at least one law enforcement agency. It is the responsibility of all staff to provide a safe environment for the residents. Any instances of employee disregard for the policies and procedures of this facility are cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. On 09/09/2020 at 12:30 PM, during an interview, with Nursing Aide (NA) #1, she stated on the morning of 08/28/2020 at approximately 12:35 AM, she observed Resident #1 on top of Resident #2, in her bed. On 09/09/2020 at 2:10 PM, during an interview with LPN #1, he stated, at around 12:45 AM on 08/28/2020, he was at the nurse's station and heard NA #1 screaming for someone to help her. He stated NA #1 told him she had seen Resident #1 in the bed on top of Resident #2 trying to stick his penis in her vagina. LPN #1 stated NA #1 helped him assess Resident #2. LPN #1 stated he called the DON and told her what NA #1 had seen, and of his assessment. He stated, within a few minutes, the DON arrived, along with the police, and shortly after that the ambulance came to pick up Resident #2 to have her checked out. LPN #1 stated, when he left at the end of his shift, Resident #1 still had a 1:1 staff member with him, and Resident #2 had not returned from the hospital. On 09/09/2020 at 3:00 PM, a joint interview with the Administrator and DON revealed, the DON had received a call around 1:00 AM on 08/28/2020 by LPN #1 that Resident #1 was found in Resident #2's room leaned over her bed holding her left hand with his left hand, and he was making sexual movements with his buttocks. The DON arrived at the same time as the police. When the ambulance was notified to come pick up Resident #2, they notified the police before the facility had an opportunity to, and so the police showed up at the same time the DON did, and the ambulance showed up a few minutes later. The DON stated she began getting statements and did an assessment of both residents before the ambulance transferred Resident #2 to the hospital. The DON revealed she notified the doctor of her findings from the assessments, and she notified the RP's (Responsible Parties) for both residents. She stated Resident #1 was placed on a 1:1 until he was transferred to a behavior unit later that afternoon. Record review of Resident #2's Departmental Notes, dated 08/28/2020 at 3:13 AM, signed by LPN #1, revealed: At 12:45 AM CNA reported that resident (Resident #1) was found standing over Resident #2's bed. MD notified. New order to transfer to ER for evaluation. At 2:30 AM officers arrived and questioned both parties. At 2:50 AM (Name of Ambulance) service was called. A record review of Resident #2's Departmental Notes, dated 08/28/2020 at 6:57 AM, signed by LPN #2, revealed: Around 6:45 AM Resident #2 returned to facility from (Name of Hospital) due to sexual assault. On 09/11/2020 at 3:40 PM, during a phone interview with the Director of the Complaint Unit for Health Facilities Licensure & Certification in Jackson, Mississippi, she validated the call log as receiving a phone call from the DON on 08/28/2020 at 4:22 AM. There were no other calls from the facility noted on the call log. An email confirming the date and time was sent for the State Agency (SA) to review. The facility submitted a Removal Plan for the IJ. Review of the Removal Plan revealed the facility took the following actions to remove the IJ: The ED called an emergency QAPI-QA meeting on 09/12/2020 at 3:15 PM to discuss IJ's called during a complaint investigation. In attendance at the emergency QAPI-QA meeting was the ED, DON, Registered Nurse (RN), RN Supervisor, and vice president of Tara Cares. Attendance by phone was the Social Service Director (SSD), Medical Director (MD), and Psychiatric Nurse Practitioner. Topics of discussion during the meeting were the aforementioned allegation of resident to resident abuse. Policy review was performed on Abuse /Neglect, Behavior management, Care plan development and implementation, monitoring and supervision of wandering residents, notification of incidents to Mississippi State Department of Health with no revisions needed. A protocol was implemented for review of physician progress notes [REDACTED]. Also discussed was the auditing charts for all residents with sexual behavior, care plans, wandering and interviewed all residents and staff for any reports of sexual abuse. 1. To meet the immediate need of Resident #2, staff assessed for any injury at the facility, and was transferred to the hospital to be evaluated by a physician. Resident #2 was provided emotional support post incident by the SSD on 08/28/2020, was added to acute charting starting 08/28/2020 indicative of nurses' monitoring and Resident # 2 was assessed by NP on 08/28/2020 after returning to the facility with no negative findings. 2. Resident # 1 was immediately placed on 1:1 surveillance by a staff member until he was transported to a Geri-psych. Resident # 1 was then discharged from the facility with his family on 09/10/2020. 3. On 8/28/2020 at 4:20 AM the DON notified Mississippi State Department of Health of the incident. 08/28/2020 at 12:50 AM the EMS notified the local police department of the incident. Police arrived at facility with EMS and investigated incident. On 09/02/2020 at 3:46 PM the ED submitted the final investigation to the Attorney General's Office. 4. An in service was initiated on 09/11/2020 at 3:00 PM by the DON for all staff present in the building on abuse and neglect, monitoring and supervision of residents and care plan implementation and development. In service to include reporting changes in behaviors for wandering residents who exhibit aggressive behaviors immediately to the Charge Nurse and initiating interventions. The Charge Nurse will communicate with the DON or RN Supervisor to determine the frequency of increased supervision based on the assessment of the residents. All staff will be in serviced prior to working the next shift. In-service was completed on 61 of 109 staff. 5. On 09/11/2020 at 5:00 PM an in service was conducted by the Regional Clinical Operations Nurse for the ED and DON to ensure reporting abuse allegations no later than 2 hours to regulatory agencies. The remaining department heads will be in service on next the scheduled shift. 6. On 09/11/2020 at 3:00 PM the ED completed 100 % audit for residents who exhibited wandering to determine any negative behavior that could be potentially harmful to other residents. Results were that 9 of 9 records reviewed and 0 found to wander and exhibit behaviors that were potentially harmful to others. 7. On 09/11/2020 the ED completed interviews with all cognitive residents to identify any reports of sexual inappropriate conduct. Results were 25 of 25 residents interviewed and all responded No. 8. On 09/11/2020 at 4:30 PM, the ED and DON completed a 100% chart audit on residents for review of care plans on all residents to identify residents with exhibited sexual behaviors. Results of the audit was 11 of 105 residents were noted with sexual behaviors and none were directed towards other residents. Results were 105 of 105 of charts audited had appropriate interventions in place. 9. On 9/11/2020 at 4:30 PM, the ED and DON audited 100% of active medical records' psych progress to determine if any implementations were warranted. No issues were identified, or implementations warranted of 105 of 105 records reviewed. The facility alleges that all corrective actions to remove the Immediate Jeopardy identified on 09/11/2020 was completed as of 09/12/2020 at 3:30 PM, for removal of the Immediate Jeopardy (IJ) on 09/12/2020. On 09/14/2020, the SA validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the IJ: The SA verified through staff interview and QAPI/QA meeting minutes review the meeting occurred and all topics to include the IJ, policy review, in-service education on abuse and neglect, chart audits, care plan revisions, and resident interviews were discussed to be implemented. 1. The SA validated through record review, Resident #2 was assessed at the facility, sent to the emergency room , has a care plan for emotional support from Social Services, and was assessed upon her return to the facility by the NP. 2. The SA validated through record review and staff interview, Resident #1 was placed on 1:1 until his transport to a Geri-psych unit. He was discharged from the facility on 09/10/2020. 3. The SA validated through record review and staff interview the reporting of the incident to the State Department of Health, EMS and Police Department notification, and a final investigation was sent to the Department of Health on 09/02/2020. 4. The SA validated through in-service sign in review, content review, and staff interview that an in-service was held for staff for all topics aforementioned on 09/11/2020 at 3:00 PM. 5. The SA validated through in-service sign in sheet and content review, as well as staff interview, an in-service was held with administration on timely reporting as of 09/11/2020 at 5:00 PM. 6. The SA validated through record review and staff interview the completion of an audit of care plans for resident who wander and have aggressive behaviors. No issues were found during the audit. 7. The SA validated through resident interviews and staff interviews, all cognitively aware residents were interviewed regarding inappropriate sexual conduct and 25 of 25 stated it had not occurred. 8. The SA validated through record review and staff interview a 100% chart audit for residents exhibiting sexual behaviors was completed, and none have behaviors directed at other residents. 9. The SA validated through record review and staff interview a 100% chart audit of psychiatric progress notes was completed and none were found with issues that needed addressed, or implementation of new orders. The SA validated on 09/14/2020, that all corrective actions had been taken by the facility to remove the IJ during the survey on 09/12/2020. The IJ was removed on 09/12/2020.

Based on record review, staff interview, and facility policy review, the facility failed to address the behaviors of Resident #1 in a manner to promote his psychosocial well-being and failed to acquire appropriate programs and services to meet the mental health and behavior needs for one (1) of five (5) residents reviewed for Behaviors and Mental Health services, Resident #1. The facility admitted Resident #1 from (Name of Behavior Unit) on [DATE] with [DIAGNOSES REDACTED]. The facility sent him out to a Behavioral Health facility on several occasions, beginning four (4) weeks after his admission, for increased behaviors, which included walking the hallways in his brief or without underwear, slapping another resident to the ground, chasing staff around the facility, impulsivity, and sexually inappropriate behaviors. On [DATE], Resident #1 was sent out to a behavior unit for sexually assaulting Resident #2. The nursing home facility did not seek recommendations as to Behavioral interventions and/or Behavioral programs for the treatment of [REDACTED]. The nursing home facility did not make referrals to address the [DIAGNOSES REDACTED]. The facility employees had no directions and/or programs to implement within the facility in order to deescalate the aggressive language, aggressive physical behaviors, and sexually inappropriate behaviors of Resident #1. There was no documentation in the medical record of Resident #1 being monitored for any of his behaviors other than hourly checks for wandering and refusing to wear a wander guard. Numerous transfers to a Behavioral Health facility were not effective in the treatment and management of Resident #1's behaviors. The facility's failure to identify and prevent the escalating aggressions and sexually inappropriate behaviors toward staff and other residents lead to the sexual abuse of Resident #2, a cognitively impaired resident, by Resident #1. Abuse was caused to Resident #2 as a result of the facility's failure to appropriately address and devise behavioral management programs for Resident #1. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE]. Resident #1 exhibited inappropriate sexual behavior towards Resident #2, who was a cognitively impaired resident. On [DATE], Resident #1 was witnessed on top of Resident #2 in her bed, attempting to engage in non-consensual sexual activity. The facility failed to care plan and put measures and interventions in place to protect residents from sexual behaviors exhibited by Resident #1. The facility's Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the IJ on [DATE] at 2:05 PM. The facility submitted a Removal Plan on [DATE] at 3:30 PM, in which the facility alleged all corrective actions to remove the IJ were completed. The State Agency (SA) validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity for CFR(s): 483.40(b)(1) - Treatment/Srvcs Mental/Psychosocial Concerns, (F742), was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: A review of the facility's Behavior Management and Psychopharmacological Medication Monitoring Protocol, last revised ,[DATE], revealed: Policy: Residents who receive antipsychotic, antidepressant, sedative/hypnotic, or anti-anxiety medications are to be maintained at the safest, lowest dose necessary to manage the residents' condition. Residents will be reviewed routinely for effectiveness and monitored for side effects of these medications and will receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. There will be an established behavior management committee that will meet routinely to review all residents mentioned above and others as the committee deems appropriate. Purpose: Residents with behaviors that are displayed routinely, that affect the resident's psychosocial well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with [REDACTED]. Responsibility: Licensed nurses, interdisciplinary team, physician, director of nursing and the pharmacy consultant. Definitions: Behavioral Interventions are individualized non-pharmacological approaches to care that are provided as part of a supportive physical and psychosocial environment, and that are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities as well as maintaining or improving a resident's mental, physical or psychosocial well-being. Procedure: Resident admitted on or currently receiving psycho-pharmacological medication: a) Determine the [DIAGNOSES REDACTED]. c) The IDT member will document in the IDT notes. d) The IDT will update the care plan to include the problem behavior, goals, and approaches. e) The planned interventions for each individual resident's behavior will be communicated to the appropriate staff members. Interventions and response will be documented. f) The Director of Nursing Services or designee will make the referral to the Behavior Management Committee. g) The committee will establish a behavior program and review behavior monitoring documentation. Appropriate updating and/or revisions to the care plan will ne done at this time ny the IDT. h) The committee will continue to routinely review the resident as long as the resident has an established behavior program and/or continues to receive psycho-pharmacological medication. i) The committee or Pharmacy Consultant will recommend the initiation, when applicable, of a gradual dose reduction, unless clinically contraindicated in an effort to maintain the resident at the lowest possible dose or to discontinue the medication. 2a) The attending physician will be notified to rule out medical causes, which may be contributing to the behavior. b) The interdisciplinary care team will update the care plan to include the problem behavior, goals and approaches. c) The director of nursing services or designee will make a referral to the behavior management committee. d) Continue to follow all steps under new admission procedure. Review of Resident #1's Departmental Notes for the day of his admission, dated [DATE] at 10:22 PM, revealed: 3:30 pm - admitted to (Formal Name of Facility). Uncooperative at first to do assessment. CNA (Certified Nurse Aide) reported that resident was uncooperative at times with care and stated, [***] you! Review of Resident #1's Departmental Notes, dated [DATE] at 9:15 PM, revealed: Resident has been ambulating this shift. He has been walking the halls with no underwear and isn't easy to redirect. He refuses all of medications, Review of Resident #1's Departmental Notes, dated [DATE] at 7:00 AM, revealed, Resident noted ambulatory to facility halls ad lib. Resident noted ambulatory to halls with shirt and pull-up only. Review of Resident #1's Departmental Notes, dated [DATE] at 6:44 AM, revealed: Resident noted up ambulatory to facility halls towards end of shift. Resident noted with pullup and t-shirt on, Resident encouraged to put on pants with several attempts. Resident ignored attempts. Resident difficult to redirect at times. Review of Resident #1's Departmental Notes, dated [DATE] at 2:04 PM, revealed, Resident aggressive when staff attempts to redirect him from going in other residents' rooms, resident gets agitated when encouraged to wear his clothes. Review of Resident #1's Departmental Notes dated [DATE] at 2:36 PM, revealed: Resident has been up wandering around facility. He is going in and out of other resident's rooms. He refuses to sit down to eat. Review of Resident #1's Departmental Notes, dated [DATE] at 3:39 PM, revealed: Resident exhibiting increased agitation and physical aggression toward staff when attempting to redirect behaviors of wandering into other resident's rooms or attempting to provide ADL care. Resident is not easily redirected. Review of Resident #1's Departmental Notes, dated [DATE] at 1:51 PM, revealed: Resident has been up wandering around facility. He is alert. He is confused. He wanders into others rooms, he can be hard to redirect at times. he would not go into room and sit down, he got agitated. Review of Resident #1's Departmental Notes, dated [DATE], revealed: Resident #1 had slapped another resident to the floor. The residents were kept separated and Resident #1 was sent to (Name of Psychiatric Unit) for further evaluation of his behaviors. No behavioral management program was devised to address Resident #1's behaviors of wandering in and out of other resident's rooms, walking the halls of the facility without underwear and pants on, and escalating behaviors with difficulty in redirecting him. As a result, Resident #1 physically abused another resident and was sent out to a psychiatric facility on [DATE], for medication management. Review of Resident #1's Departmental Notes, dated [DATE] at 2:43 PM, revealed: Resident returned to facility from (Name of Psychiatric Unit) via (Name of Transportation Company) at approximately 2:30 PM, Resident refused to get off the van initially. A review of Resident #1's Psychiatric Progress note, dated [DATE], revealed: Chief Complaint: Behavioral Aggression. Subjective: 55 y/o (year old) AA (African American) male assessed and evaluated as a result of behavioral disturbances, difficulty redirecting, and socially inappropriate behaviors that are disruptive to the facility. Continues to chase staff around the facility. Sexually inappropriate at times difficult to redirect. Insight and Judgment remain grossly impaired. Objective: + (positive) for impulsivity sexually inappropriate. Chases staff around the facility. Assessment: Ongoing behavioral aggression and agitation not remedied by routine regimen. Intermittent outbursts require [MEDICATION NAME] IM (intramuscularly) due to level of aggression and potential to harm self and others. On [DATE] at 3:35 PM, during an interview with Nurse Practitioner #1, the author of the Psychiatric Progress Note on [DATE], she stated, she remembered being at the facility and being told Resident #1 was chasing staff, because he chased her around the unit as she was making her rounds. She stated she didn't feel threatened by him doing this because he wasn't sexually inappropriate with her and she was not a vulnerable adult. She couldn't remember the name of the staff member that had talked to her about his sexual behaviors, however, she remembered them needing to use [MEDICATION NAME] injections to keep him calm. No behavioral management program was devised to address Resident #1's behaviors of chasing staff around the facility, impulsivity, or sexually inappropriate behaviors with difficulty being redirected at times. Review of Resident #1's Departmental Notes dated [DATE], revealed: Resident #1 in dayroom and reported by another resident, that a resident was reaching for Resident #1's drink off the table and Resident #1 hit her Redirected Resident #1 not to hit other residents. Resident #1 nodded head in a yes motion in understanding. No behavioral management program was devised to address the incident of physical aggression on [DATE], with another resident. As a result, Resident #1 had another physically aggressive altercation with another resident on [DATE] and was sent out again to a psychiatric unit for treatment. Review of Resident #1's Department Notes, dated [DATE] at 1:18 PM, revealed: 9:15 AM reported by resident that this resident (Resident #1) had hit him in the face. This nurse asked this resident did he hit (Formal name) in his room. This resident (Resident #1) stated yes . orders from MD (Medical Director) to transfer to inpatient facility . Resident #1 returned to the facility on [DATE]. No behavioral management program was devised to address the incident of physical aggression on [DATE], with another resident. As a result, Resident #1 had another physically aggressive altercation with another resident on [DATE]. Review of Resident #1's Departmental Notes, dated [DATE] at 4:00 PM, revealed: At approx. 1400 hours (2:00 PM) front hall nurse notified this nurse that a resident stated this resident (Resident #1) slapped him last night and pushed him out the room. This nurse interviewed this resident (Resident #1) and (asked) him if he slapped (Formal name) and this resident (Resident #1) stated hell no . Nurse asked if he pushed (Formal name) out of the room and this resident (Resident #1) shook head yes . This resident (Resident #1) and (Formal name) were immediately separated with room change and placed one on one . No behavioral management program was devised to address the incident of physical aggression on [DATE], with another resident. As a result, Resident #1 had another physically aggressive altercation with another resident in early [DATE] and was sent out again to a psychiatric unit for treatment, with return to the facility on [DATE]. No behavioral management program was devised to address the incident of physical aggression in early [DATE], with another resident. A review of Resident #1's Department Notes, dated [DATE] at 3:06 AM, revealed: At 1245 AM Resident #1 observed in (Room Number) with clothing down with hand on his penis on top of Resident #2 per CNA. Resident #1 questioned per writer and law enforcement x 4 on what he was doing across the hallway. Resident wouldn't answer clearly. An addendum note was done on [DATE] at 3:31 AM which revealed, 1 on 1 initiated. On [DATE] at 3:00 PM, during a joint interview with the Administrator and DON, the Administrator stated, Resident #1 had care plans for being aggressive and had several residents to resident incidents where he slapped them, but nothing ever sexual. The Administrator verified Resident #1 had been sent out in April and December of 2019 and January and [DATE] for physically aggressive altercations with other residents on the South Unit. When the Administrator and DON were asked what interventions were put into place after his physically aggressive behaviors with other residents, the DON stated he was on hourly checks by staff, and the Administrator indicated that was more for his elopement risk because he refused to wear a wander-guard and was known to walk all over the building, and sometimes in and out of other residents rooms. During an interview with the Social Service Director (SSD) for the South Unit, on [DATE] at 12:48 PM, he stated that he had been made aware of the sexual assault of Resident #2 by Resident #1 on [DATE]. He stated he was not made aware of the behaviors recorded on the progress note from [DATE], and due to that, they were not care planned. The SSD did indicate Resident #1 had a significant history of being physically aggressive with other residents on several occasions, and with staff in resisting care, and he had multiple care plans to address his aggressive behaviors, and his medications were tracked for gradual dose reductions, however, there was no formal behavior management program for him. When asked by the State Agency (SA) what interventions were put into place after each of Resident #1's aggressive physical altercations with other residents, he stated they would separate him from the other resident, and usually sent him out the psychiatric unit for medication adjustments. When asked by the SA if they increased the frequency in which they observed and supervised him, he stated they had him on one (1) hour checks due to his refusal to wear a wander guard and walking all over the facility, however, it was not to address his behaviors. The SSD stated that he had not seen Resident #1 be sexually inappropriate to any other residents prior to the incident of sexual assault on [DATE]. The facility submitted a Removal Plan for the IJ. Review of the Removal Plan revealed the facility took the following actions to remove the IJ: The ED called an emergency QAPI-QA meeting, on [DATE] at 3:15 PM, to discuss IJ's called during a complaint investigation. In attendance at the emergency QAPI-QA meeting was the ED, DON, Registered nurse (RN), RN Supervisor, and vice president of Tara Cares. Attendance by phone was the Social Service Director (SSD), Medical Director (MD), and Psychiatric Nurse Practitioner. Topics of discussion during the meeting were the aforementioned allegation of resident to resident abuse. Policy review was performed on Abuse /Neglect, Behavior management, Care plan development and implementation, monitoring and supervision of wandering residents, notification of incidents to Mississippi State Department of Health with no revisions needed. A protocol was implemented for review of physician progress notes [REDACTED]. Also discussed was the auditing charts for all residents with sexual behavior, care plans, wandering and interviewed all residents and staff for any reports of sexual abuse. 1. To meet the immediate need of Resident #2, staff assessed for any injury at the facility, and was transferred to the hospital to be evaluated by a physician. Resident #2 was provided emotional support post incident by the SSD on [DATE], was added to acute charting starting [DATE] indicative of nurses' monitoring and Resident # 2 was assessed by NP on [DATE] after returning to the facility with no negative findings. 2. Resident # 1 was immediately placed on 1:1 surveillance by a staff member until he was transported to a Geri-psych. Resident # 1 was then discharged from the facility with his family on [DATE]. 3. On [DATE] at 4:20 AM, the DON notified Mississippi State Department of Health of the incident. [DATE] at 12:50 AM, the EMS notified the local police department of the incident. Police arrived at facility with EMS and investigated incident. On [DATE] at 3:46 PM the ED submitted the final investigation to the Attorney General's Office. 4. An in service was initiated, on [DATE] at 3:00 PM, by the DON for all staff present in the building on abuse and neglect, monitoring and supervision of residents and care plan implementation and development. In service to include reporting changes in behaviors for wandering residents who exhibit aggressive behaviors immediately to the Charge Nurse and initiating interventions. The Charge Nurse will communicate with the DON or RN Supervisor to determine the frequency of increased supervision based on the assessment of the residents. All staff will be in serviced prior to working the next shift. In-service was completed on 61 of 109 staff. 5. On [DATE] at 5:00 PM, an in service was conducted by the Regional Clinical Operations Nurse for the ED and DON to ensure reporting abuse allegations no later than 2 hours to regulatory agencies. The remaining department heads will be in service on next the scheduled shift. 6. On [DATE] at 3:00 PM, the ED completed 100% audit for residents who exhibited wandering to determine any negative behavior that could be potentially harmful to other residents. Results were that 9 of 9 records reviewed and 0 found to wander and exhibit behaviors that were potentially harmful to others. 7. On [DATE], the ED completed interviews with all cognitive residents to identify any reports of sexual inappropriate conduct. Results were 25 of 25 residents interviewed and all responded No. 8. On [DATE] at 4:30 PM, the ED and DON completed a 100% chart audit on residents for review of care plans on all residents to identify residents with exhibited sexual behaviors. Results of the audit was 11 of 105 residents were noted with sexual behaviors and none were directed towards other residents. Results were 105 of 105 of charts audited had appropriate interventions in place. 9. On [DATE] at 4:30 PM, the ED and DON audited 100% of active medical records' psych progress to determine if any implementations were warranted. No issues were identified, or implementations warranted of 105 of 105 records reviewed. The facility alleges that all corrective actions to remove the Immediate Jeopardy identified on [DATE] was completed as of [DATE] at 3:30 PM, for removal of the Immediate Jeopardy (IJ) on [DATE]. On [DATE], the SA validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review, Resident #2 was assessed at the facility, sent to the emergency room , has a care plan for emotional support from Social Services, and was assessed upon her return to the facility by the NP. 2. The SA validated through record review and staff interview, Resident #1 was placed on 1:1 until his transport to a Geri-psych unit. He was discharged from the facility on [DATE]. 3. The SA validated through record review and staff interview the reporting of the incident to the State Department of Health, EMS and Police Department notification, and a final investigation was sent to the Department of Health on [DATE]. 4. The SA validated through in-service sign in review, content review, and staff interview that an in-service was held for staff for all topics aforementioned on [DATE] at 3:00 PM. 5. The SA validated through in-service sign in sheet and content review, as well as staff interview, an in-service was held with administration on timely reporting as of [DATE] at 5:00 PM. 6. The SA validated through record review and staff interview the completion of an audit of care plans for resident who wander and have aggressive behaviors. No issues were found during the audit. 7. The SA validated through resident interviews and staff interviews, all cognitively aware residents were interviewed regarding inappropriate sexual conduct and 25 of 25 stated it had not occurred. 8. The SA validated through record review and staff interview a 100% chart audit for residents exhibiting sexual behaviors was completed, and none have behaviors directed at other residents. 9. The SA validated through record review and staff interview a 100% chart audit of psychiatric progress notes was completed and none were found with issues that needed addressed, or implementation of new orders. The SA validated on [DATE], that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE]. The IJ was removed on [DATE].

Based on record review, facility policy review, and staff interview, the facility failed to protect Resident #2, a cognitively impaired resident, from non-consensual, sexual abuse by Resident #1, for one (1) of five (5) residents reviewed for abuse, neglect, and exploitation, Resident #2. On Friday, [DATE] at 12:35 AM, a staff member, Nursing Aide (NA) #1, was rounding and walked past a resident's room and witnessed Resident #1 on top of Resident #2 in her bed. NA #1 ran into the room, pulled back the privacy curtain, and witnessed Resident #1 on top of Resident #2, holding her hands above her head with his left hand, and his right hand (which was not visible) holding his penis and attempting to guide it into Resident #1's vagina, all while making sexually mannered movements with his pelvis. Resident #2 was crying and saying, please stop it, please stop it. NA #1 began to call Resident #1's name and told him to stop, while physically trying to remove him from Resident #2's bed. When she couldn't move him, NA #1 ran to the door and screamed for help. As the nurse, Licensed Practical Nurse (LPN) #1, came up the hallway to Resident #2's room, he saw Resident #1 run out of the room with his pants down, and underwear visible, holding onto the sides of his pants to keep them from falling off. An assessment of Resident #2 was immediately done by LPN #1 with the assistance of NA #1. Resident #2's brief had been torn and pulled to the side, with a small area of blood near the tab of the brief, and another small spot of blood on the front, outside of the brief. There was no outward appearance of injury to her perineal area. A physician's orders [REDACTED].#2 to the hospital to be assessed, and she was found to have a labial abrasion and skin tears to her perineal area and to her vagina consistent with sexual assault. Resident #1 was immediately placed on 1:1 and was subsequently transferred to a geri-psych unit later that afternoon. A record review revealed that Resident #1 had been involved in multiple incidents of physical and verbal aggression toward other residents and staff in the facility and had been resistant to care since the day of his admission on [DATE]. One instance of physical aggression even facilitated a room change to separate him from his former roommate. A psychiatric progress note, dated [DATE], revealed, an in-facility visit due to behavioral aggression. It noted Resident #1 to be socially inappropriate, disruptive to the facility, chasing staff around the facility, being sexually inappropriate and difficult to redirect at times. The note further stated he was having issues with impulsivity and being sexually inappropriate with ongoing behavioral aggression and agitation not remedied by his routine regimen. Intermittent outbursts required [MEDICATION NAME] IM (intramuscularly) due to his level of aggression and potential to harm self and others. Review of Resident #1's care plans, and Departmental Notes revealed he wanders in and out of other resident's rooms frequently, he can be hard to redirect, becoming agitated and aggressive at times. There was no mention of Resident #1's impulsivity, chasing staff, or sexually inappropriate behaviors in his care plan or Social Services notes. The facility's failure to protect Resident #2 from inappropriate sexual behaviors by Resident #1, resulted in Resident #2 being sexually abused on [DATE] by Resident #1, and placed other residents at risk in a situation that was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) on [DATE], which began on [DATE], when Resident #1 exhibited inappropriate sexual behavior towards Resident #2, who is a cognitively impaired resident. On [DATE], Resident #1 was witnessed on top of Resident #2 in her bed, attempting to engage in non-consensual sexual activity. The facility failed put measures and interventions in place to protect residents from sexual behaviors exhibited by Resident #1. The facility's Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the IJ and SQC on [DATE] at 2:05 PM. The facility submitted a Removal Plan on [DATE] at 3:30 PM, in which the facility alleged all corrective actions to remove the IJ were completed. The State Agency (SA) validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity for 42 CFR(s):483.12(a)(1) - Free from Abuse, Neglect, and Exploitation, (F600) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Abuse Prevention Policy, last revised ,[DATE], revealed, the facility is committed to protecting the residents from abuse by anyone. Definitions included: Abuse - willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Abuse may be resident-to-resident, staff-to-resident, family-to-resident, or visitor-to-resident. Sexual Abuse - This includes but is not limited to sexual harassment, sexual coercion or sexual assault, or non-consensual sexual contact of any type with a resident. Employees will be trained through orientation and on-going sessions on issues related to abuse prohibition practices such as: appropriate interventions to deal with aggressive and/or catastrophic reaction of residents, and what constitutes abuse. To protect residents, suspected or substantiated cases of resident abuse shall be thoroughly investigated, documented, and reported to the physician, families and/or representatives, and as required by state guidelines. In addition, the facility will follow Section 1150B of the Social Security Act's time limits for reporting a reasonable suspicion of crime (immediately but no later than 2 hours if abuse or serious bodily injury and 24 hours for all others). In addition to reporting to the State Agency, a reasonable suspicion of crime or allegation of abuse is to be reported to at least one law enforcement agency. It is the responsibility of all staff to provide a safe environment for the residents. The State Agency (SA) was unable to interview Resident #1, as he remained in a geri-psych unit during the survey. Review of Resident #1's Quarterly Minimum Data Set (MDS), dated [DATE], revealed, he had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Resident #1 had unclear speech and was sometimes understood in making concrete requests. He was usually able to understand most conversation. Resident #1 had behaviors of [MEDICAL CONDITION] marked. Resident #1 required no assistance with walking in his room, and supervision when walking in the corridors. He had [DIAGNOSES REDACTED]. During an observation and interview on [DATE] at 2:45 PM, with Resident #2, she was resting in her bed with her eyes closed. She opened her eyes when her name was spoken and smiled. When asked how she was feeling she responded, I'm okay baby, I'm doin' okay. When asked if anyone had ever hurt her, if male residents ever came into her room, and if she was ever afraid, she replied the same answer every time, Oh no baby, I'm fine. Resident #2 was smiling and friendly. Review of Resident #2's Admission 5-day Minimum Data Set (MDS), dated [DATE], revealed, she had a BIMS score of one (1), which indicated severe cognitive impairment, making her not interviewable. She had unclear mumbled words, sometimes understood, and sometimes understands what is being said to her. Resident #2 required limited assistance to eat, and extensive to total assistance for the remainder of her activities of daily living (ADL's). She had a [DIAGNOSES REDACTED]. On [DATE] at 12:30 PM, during an interview with Nursing Aide (NA) #1, she stated on the morning of [DATE] at approximately 12:35 AM, she was doing her walking rounds to check on her residents. NA #1 stated she was working with another male aide on the South unit. She revealed she was to check on the female residents, and the male aide was to check on all the male residents during rounds. NA #1 stated as she passed Resident #2's room, lightening struck outside and lit up the room. She stated that she saw a pair of brown pants on top of the bed, with the buttocks up and knew it wasn't Resident #2. NA #1 stated she could hear Resident #2 crying and saying, Please stop it, please stop it. She stated that she ran into the room and pulled back the privacy curtain to see Resident #1 on top of Resident #2, in her bed. She revealed, Resident #1,with his left hand, he had both of Resident #2's hands pinned above her head, and with his right hand, he appeared to be holding his penis and attempting to place it in Resident #2's vagina. NA #1 stated the whole time, Resident #1 was making a sexual humping motion with his pelvis. NA #1 stated she began screaming Resident #1's name and put her hand on his arm trying to remove him off Resident #2, while screaming for him to stop and get off Resident #2. She revealed, Resident #1 was a large man, well over 200 pounds. She stated when Resident #1 wouldn't listen to her and she couldn't remove him from the bed, she ran into the doorway and started screaming for help. She stated LPN #1 heard her and came running toward the room. NA #1 stated as LPN #1 neared the doorway of Resident #2's room, Resident #1 ran out the door past her and jumped in his bed, pulling the blankets up to his chin, and pretended to be snoring. She stated, LPN #1 asked Resident #2 if she was hurt and she said, Nothing happened, he just tried to have me. NA #1 revealed she assisted LPN #1 with assessing Resident #2, and found her nightgown pulled to the side, and her adult brief torn loose on one side and pulled open and over to the side. She stated there was a spot of blood, about a quarter size near the tab of the brief, and another spot of blood that same size on the outside front of the brief. NA #1 stated she assisted LPN #1 in doing a perineal exam, looking at her thighs and vaginal area, and didn't see any blood from the outside. She revealed Resident #2 was sick and had an IV (intravenous) line in to get some fluids for dehydration and a lack of appetite. NA #1 stated they both looked at Resident #2's IV to see if it was bleeding, but it wasn't, and the IV remained intact. She stated Certified Nursing Assistant (CNA) #1 was told to stay with Resident #1 as a 1:1 until management staff could get there. She revealed Resident #2 was sent to the hospital to be checked out, but before she left for the hospital, the Director of Nursing (DON) and the police arrived and interviewed Resident #1 and Resident #2. On [DATE] at 2:10 PM, during an interview with LPN #1, he stated, at around 12:45 AM on [DATE], he was at the nurses' station and heard NA #1 screaming for someone to help her. He stated as he was running down the hall to Resident #2's room, he saw Resident #1 walking quickly out of Resident #2's doorway, past NA #1 and go into his room. LPN #1 revealed Resident #1's pants were down, with his underwear exposed, and he was holding his pants up. He stated NA #1 told him she had seen Resident #1 in the bed on top of Resident #2 trying to stick his penis in her vagina. LPN #1 also stated, NA #1 told him, from her angle, she couldn't see his penis, but it appeared that Resident #1 was trying to hold it with one hand, and he was holding Resident #2's hands/arms down with his other hand. LPN #1 revealed that Resident #2 was very tiny and Resident #1 was a bigger guy. He revealed NA #1 helped him to assess Resident #2. LPN #1 confirmed Resident #2's brief was torn and there was a small spot of blood on the side of it. LPN #1 stated Resident #1 was still crying when he got to the room. He revealed that he asked Resident #2 if she had been hurt, and she said, Nothing happened, he just tried to have me. LPN #1 stated there was no evidence of injury from the outside of her peri-area or on her thighs. He revealed CNA #1 had been sitting with Resident #1. LPN #1 revealed that he asked Resident #1 why he had been in Resident #2's room, but he wouldn't answer any of his questions. LPN #1 stated he called the DON and told her what NA #1 had seen, and of his assessment. LPN #1 stated within a few minutes, the DON arrived along with the police, and shortly afterwards, the ambulance came to pick up Resident #2 to have her checked out. LPN #1 stated the police came in to talk to Resident #1 while he was in there. He stated, they (police) asked Resident #1 if he was in Resident #2's room and if he had hurt her, and Resident #1 replied yes, but then he refused to answer anymore questions, stating I ain't saying nothing. LPN #1 revealed, when he left at the end of his shift, Resident #1 still had a 1:1 staff member with him, and Resident #2 had not returned from the hospital. The State Agency (SA) attempted to reach the CNA #1 several times, but was not able to speak to him for interview. On [DATE] at 3:00 PM, a joint interview with the Administrator and DON, revealed, the DON stated she had received a call around 1:00 AM on [DATE] from LPN #1 that Resident #1 was found in Resident #2's room, leaned over her bed holding her left hand with his left hand, and he was making sexual movements with his buttocks. The DON revealed she arrived at the facility at the same time as the police. The DON revealed, when the ambulance was notified to come pick up Resident #2, they (ambulance service) notified the police before the facility had an opportunity to. The DON revealed she began getting statements and did an assessment of both residents before the ambulance transferred Resident #2 to the hospital. The DON stated she notified the doctor of her findings from the assessments, and she notified the RPs (Responsible Parties) for both residents. She stated Resident #1 was placed on 1:1 observation until he was transferred to a behavior unit in Memphis, TN later that afternoon. Both the Administrator and DON stated it was unpredictable behavior for Resident #1, and they both felt he had not had sex with Resident #2 because his pants appeared up from the back, and NA #1 never saw Resident #1's actual penis or him penetrating Resident #2. An assessment of Resident #2 revealed no blood on her peri-area or any visible injury. They both stated there had never been a sexual problem with Resident #1 prior to this incident, and they felt they had stopped him before he could assault her. The Administrator stated Resident #1 had care plans for being aggressive and had several resident to resident incidents where he slapped them, but nothing ever sexual. The Administrator verified Resident #1 had been sent out in April and December of 2019, and January and [DATE] for physically aggressive altercations with other residents on the South Unit. When the Administrator and DON were asked what interventions were put into place after his physically aggressive behaviors with other residents, the DON stated he was on hourly checks by staff, and the Administrator indicated that was more for Resident #1's elopement risk because he refused to wear a wander-guard and was known to walk all over the building, and sometimes in and out of other residents rooms. When the SA asked if either of them had read the Hospital report from the emergency room , and the Progress note dated [DATE] that were all in the investigative folder they gave to the State Agency surveyor, neither of them answered. The SA read aloud the hospital report, which stated Resident #2 was non-verbal and exhibited signs and symptoms of abuse, sustained painful groin injuries which included an abrasion to her left inner labia, a tear to her perineal area, and vaginal tears. Her diaper with blood and urine was kept for evidence, and a rape kit was done. When the SA asked them both if during their investigation, they discovered what had caused the abrasions to her labia and the skin tears to her perineal area and vagina, the Administrator stated, he (Resident #1) did have some long fingernails, that could have done it. When asked by the SA if digital penetration was considered sexual abuse according to the facility's policy, she stated, yes. The SA then read aloud the Progress note written on [DATE] by Resident #1's psychiatric provider which stated the chief complaint to be behavioral aggression. The progress note revealed Resident #1 to be assessed and evaluated as a result of behavioral disturbances, difficulty redirecting, and socially inappropriate behaviors that are disruptive to the facility. He continues to chase staff around the facility and is sexually inappropriate at times and difficult to redirect. Resident #1 was + (positive) for impulsivity and sexually inappropriate. Under the Assessment portion of the note, it stated, Resident #1's ongoing behavioral aggression and agitation was not remedied by routine regimen and intermittent outbursts required [MEDICATION NAME] IM due to the level of aggression and potential to harm self or others. The DON stated that she remembered him chasing staff around, and he even chased the Nurse Practitioner around while she was here, but she didn't remember him being sexually inappropriate. The Administrator then asked the DON to step out of the room because she needed to talk to the SA. Once the DON left the room, the Administrator asked to read the progress note the SA had just read to them. After the SA handed her the note, she folded it in half and placed it under her note book and stated, You can forget you ever saw that piece of paper for me, right? The SA stated, that she could not and needed the documentation back from her. The Administrator stood up, slid the folded paper back to me and stated, God damn it, I copied the wrong papers. I screwed up and made a big mistake. Oh God, Oh God, this is horrible, my boss is gonna kill me for giving you the wrong papers. I meant to give you the progress note from October or November, not that one. That's another IJ on my watch. She is liable to send me to the house for good. Oh God, Oh God, this is bad, this is gonna be terrible. She then walked out of the conference room. On [DATE] at 3:35 PM, during an interview with Nurse Practitioner (NP) #1, she stated, she remembered being at the facility and being told Resident #1 was chasing staff, because he had chased her around the unit as she was making her rounds. She stated she didn't feel threatened by him doing this because he wasn't sexually inappropriate with her and she was not a vulnerable adult. NP #1 stated she couldn't remember the name of the staff member that had talked to her about his sexual behaviors, however, she remembers them needing to use [MEDICATION NAME] injections to keep him calm. She stated it had been 15 months ago and she didn't remember all the details, however, in her dealings with Resident #1 since then, he had been pleasant and agreeable during their visits. On [DATE] at 4:10 PM, during an interview with the Medical Director (MD), he stated, he had been Resident #1's primary medical doctor prior to him being placed in the nursing facility, and during his stay. The MD revealed he had not been made aware of any sexual behaviors until this incident, however, he knew he had a proclivity to being physically aggressive. He stated he was made aware of the incident early in the morning on [DATE], and a NP had come to assess Resident #2 after she returned from the hospital to ensure she was doing okay. Record review of Resident #2's Departmental Notes, dated [DATE] at 3:13 AM, signed by LPN #1 revealed: At 12:45 AM, a CNA reported that resident (Resident #1) was found standing over resident's bed. Upon assessment resident had diaper unfastened. Separated per CNA. Small amount of blood on diaper. No visible trauma to vaginal area. No pain voiced. Denies any discomfort. Denies anything happened. Responsible Party (RP) #2 notified when RP #1 didn't answer. MD notified. New order to transfer to ER for evaluation. At 2:30 AM officers arrive et question both parties. At 2:50 AM (Name of ambulance) service called, one male and one female attendee assisted resident to stretcher. No signs and symptoms of distress. Record review of Resident #2's Departmental Notes, dated [DATE] at 6:57 AM, signed by LPN #2, revealed: Around 6:45 AM resident returned to facility from (Name of Hospital) due to sexual assault. Record review of Resident #1's Departmental Notes, dated [DATE] at 3:06 AM, and signed by LPN #1, revealed: At 12:45 AM, resident observed in RM (room) S30W with clothing down with hand on his penis on top of resident (Resident #2) per CNA. Resident questioned per writer and law enforcement times four (4) on what he was doing across hallway. Resident wouldn't answer clearly enough to be understood. RP notified of resident's action. Voiced some understanding. Resident joking and smiling when officers exited building. Denies any pain or discomfort. An addendum to this note, dated [DATE] at 3:31 AM, signed by LPN #1, revealed, One on one initiated. Review of Resident #1's Behavior/Pain Medication Monitoring Summary, dated [DATE], revealed: Current behaviors as easily agitated, refusing/resisting care, mood changes, verbal aggression, and being manipulative. He was noted to still have these behaviors. A follow up was added on [DATE], which revealed a medication change from [MEDICATION NAME] to Klonopin because of behaviors. Review of Resident #1's Care Plan, with a Problem Onset date of [DATE], revealed, Problem/Need: I am on BMP (Behavior Management Plan) for easily agitated, manipulative, mood change, verbal/physical aggression, attention seeking, wandering in other rooms, refuse care. Goal and Target Date: Resident will decrease behaviors by next ARD. Approaches: Redirect behaviors as they occur, social visit as needed, approach resident in a calm manner, review medication monthly, observe resident for changes in mood behavior and psychosocial well-being, provide with activities of interest and encourage participation, consult psychiatrist as needed, and SCU as needed. There was no mention of sexually inappropriate behaviors, interventions pertaining to being sexually inappropriate, or monitoring Resident #1's whereabouts due to wandering in other residents' rooms. Review of Resident #1's care plan, with a Problem Onset date of [DATE], revealed, Problem/Need: Resident is at risk for wandering and elopement. Resident refuses to wears a wanderguard bracelet AEB (as evidenced by) several times. Goal & Target date: Resident will have no successful elopement, and resident will not leave facility without staff knowledge. Approaches: Monitor resident whereabouts every hour, redirect wandering and elopement behaviors, and alert staff to resident is wandering behavior. During an interview, on [DATE] at 10:30 AM, with the Administrator, she stated, Resident #1 was scheduled to come back to the facility today. She revealed that she had called his family and the Geri-psych unit and asked for them to seek alternative placement for him. During an interview, on [DATE] at 11:15 AM, with the Administrator, she stated that she had spoken with Resident #1's family and they had found another place for him to go and he would not be returning to the facility. The Administrator stated that the family was coming to pick up his belongings that afternoon. The facility submitted a Removal Plan for the IJ. Review of the Removal Plan revealed the facility took the following actions to remove the IJ: The ED called an emergency QAPI-QA meeting, on [DATE] at 3:15 PM, to discuss IJ's called during a complaint investigation. In attendance at the emergency QAPI-QA meeting was the ED, DON, Registered Nurse (RN), RN Supervisor, and vice president of Tara Cares. Attendance by phone was the Social Service Director (SSD), Medical Director (MD), and Psychiatric Nurse Practitioner. Topics of discussion during the meeting were the aforementioned allegation of resident to resident abuse. Policy review was performed on Abuse /Neglect, Behavior management, Care plan development and implementation, monitoring and supervision of wandering residents, notification of incidents to Mississippi State Department of Health with no revisions needed. A protocol was implemented for review of physician progress notes [REDACTED]. Also discussed was the auditing charts for all residents with sexual behavior, care plans, wandering and interviewed all residents and staff for any reports of sexual abuse. 1. To meet the immediate need of Resident #2, staff assessed for any injury at the facility, and was transferred to the hospital to be evaluated by a physician. Resident #2 was provided emotional support post incident by the SSD on [DATE], was added to acute charting starting [DATE] indicative of nurses' monitoring and Resident # 2 was assessed by NP on [DATE] after returning to the facility with no negative findings. 2. Resident # 1 was immediately placed on 1:1 surveillance by a staff member until he was transported to a Geri-psych. Resident # 1 was then discharged from the facility with his family on 9.10.2020. 3. On [DATE] at 4:20 AM the DON notified Mississippi State Department of Health of the incident. [DATE] at 12:50AM the EMS notified the local police department of the incident. Police arrived at facility with EMS and investigated incident. On [DATE] at 3:46 PM the ED submitted the final investigation to the Attorney General's Office. 4. An in service was initiated on [DATE] at 3:00 PM by the DON for all staff present in the building on abuse and neglect, monitoring and supervision of residents and care plan implementation and development. In service to include reporting changes in behaviors for wandering residents who exhibit aggressive behaviors immediately to the Charge Nurse and initiating interventions. The Charge Nurse will communicate with the DON or RN Supervisor to determine the frequency of increased supervision based on the assessment of the residents. All staff will be in serviced prior to working the next shift. In-service was completed on 61 of 109 staff. 5. On [DATE] at 5:00 PM, an in service was conducted by the Regional Clinical Operations Nurse for the ED and DON to ensure reporting abuse allegations no later than 2 hours to regulatory agencies. The remaining department heads will be in service on next the scheduled shift. 6. On [DATE] at 3:00 PM, the ED completed 100% audit for residents who exhibited wandering to determine any negative behavior that could be potentially harmful to other residents. Results were that 9 of 9 records reviewed and 0 found to wander and exhibit behaviors that were potentially harmful to others. 7. On [DATE], the ED completed interviews with all cognitive residents to identify any reports of sexual inappropriate conduct. Results were 25 of 25 residents interviewed and all responded No. 8. On [DATE] at 4:30 PM, the ED and DON completed a 100% chart audit on residents for review of care plans on all residents to identify residents with exhibited sexual behaviors. Results of the audit was 11 of 105 residents were noted with sexual behaviors and none were directed towards other residents. Results were 105 of 105 of charts audited had appropriate interventions in place. 9. On [DATE] at 4:30PM, the ED and DON, audited 100% of active medical records' psych progress to determine if any implementations were warranted. No issues were identified, or implementations warranted of 105 of 105 records reviewed. The facility alleges that all corrective actions to remove the Immediate Jeopardy identified on [DATE] was completed as of [DATE] at 3:30PM, for removal of the Immediate Jeopardy (IJ) on [DATE]. On [DATE], the SA validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the IJ: The SA verified through staff interview and QAPI/QA meeting minutes review the meeting occurred and all topics to include the IJ, policy review, in-service education on abuse and neglect, chart audits, care plan revisions, and resident interviews were discussed to be implemented. 1. The SA validated through record review, Resident #2 was assessed at the facility, sent to the emergency room , has a care plan for emotional support from Social Services, and was assessed upon her return to the facility by the NP. 2. The SA validated through record review and staff interview, Resident #1 was placed on 1:1 until his transport to a Geri-psych unit. He was discharged from the facility on [DATE]. 3. The SA validated through record review and staff interview the reporting of the incident to the State Department of Health, EMS and Police Department notification, and a final investigation was sent to the Department of Health on [DATE]. 4. The SA validated through in-service sign in review, content review, and staff interview that an in-service was held for staff for all topics aforementioned on [DATE] at 3:00 PM. 5. The SA validated through in-service sign in sheet and content review, as well as staff interview, an in-service was held with administration on timely reporting as of [DATE] at 5:00 PM. 6. The SA validated through record review and staff interview the completion of an audit of care plans for resident who wander and have aggressive behaviors. No issues were found during the audit. 7. The SA validated through resident interviews and staff interviews, all cognitively aware residents were interviewed regarding inappropriate sexual conduct and 25 of 25 stated it had not occurred. 8. The SA validated through record review and staff interview a 100% chart audit for residents exhibiting sexual behaviors was completed, and none have behaviors directed at other residents. 9. The SA validated through record review and staff interview a 100% chart audit of psychiatric progress notes was completed and none were found with issues that needed addressed, or implementation of new orders. The SA validated on [DATE], that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE]. The IJ was removed on [DATE].

Based on facility policy and procedure review, staff interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan related to Behaviors, for one (1) of five (5) resident care plans reviewed, Resident #1. On [DATE], Nurse Practitioner (NP) #1 assessed and evaluated Resident #1 at the facility, for a chief complaint of Behavioral Aggression. The progress note revealed, Resident #1 was being assessed and evaluated as a result of behavioral disturbances, difficulty redirecting, and socially inappropriate behaviors that were disruptive to the facility. NP #1 wrote Resident #1 continues to chase staff around the facility. Sexually inappropriate at times difficult to redirect. Further review of the note revealed, Resident #1 was positive (+) for impulsivity, sexually inappropriate. Chases staff around the facility. Ongoing behavioral aggression and agitation not remedied by routine regimen. Intermittent outbursts require [MEDICATION NAME] IM due to level of aggression and potential to harm self and others. A record review of Resident #1's care plan revealed the sexually inappropriate behavior, and impulsivity was not care planned. On Friday, [DATE] at 12:35 AM, a staff member was rounding and walked past a resident's room and witnessed Resident #1 on top of Resident #2 in her bed, without her consent, moving his body in a sexual manner. After removal of Resident #1 from on top of Resident #2, staff observed Resident #2's adult brief pulled to the side, and blood on the brief. Assessment of Resident #2 at the hospital verified injuries consistent with sexual assault. The facility failed to care plan and provide close supervision and appropriate Behavioral Interventions for Resident #1. The facility's failure to develop and implement a comprehensive person-centered care plan to address sexually inappropriate behaviors, and the impulsivity of Resident #1, and for staff to be aware of these behaviors and not put interventions in place to prevent further abuse, placed Resident #2 and other residents in a situation that was likely to cause serious harm, injury, impairment or death. The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on [DATE]. Resident #1 exhibited inappropriate sexual behavior towards Resident #2, who is a cognitively impaired resident. On [DATE], Resident #1 was witnessed on top of Resident #2 in her bed, attempting to engage in non-consensual sexual activity. The facility failed to care plan and put measures and interventions in place to protect residents from sexual behaviors exhibited by Resident #1. The facility's Administrator, Director of Nursing (DON), and Nurse Consultant were notified of the IJ and SQC, on [DATE] at 2:05 PM. The facility submitted a Removal Plan on [DATE] at 3:30 PM, in which the facility alleged all corrective actions to remove the IJ were completed. The State Agency (SA) validated the facility's Removal Plan on [DATE] and determined the IJ was removed on [DATE]. Therefore, the scope and severity for CFR(s):483.21(b)(1) - Develop/Implement Comprehensive Care Plan, (F656) was lowered from a J to a scope and severity of a D level, while the facility develops and implements a plan of correction and monitors the effectiveness of the systemic changes to ensure the facility sustains compliance with regulatory requirements. Findings include: Review of the facility's Comprehensive Person-Centered Care Plans policy, last updated ,[DATE], revealed: Each resident will have a person-centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. The Interdisciplinary Tearm (IDT) along with the resident and/or Resident Representative will identify resident problems, needs, strengths, life history, preferences, and goals. For each problem, need or strength a resident-centered goal is developed. Goals should be measurable. The comprehensive care plan can be reviewed and/or revised at quarterly intervals in conjunction with the completion of MDS quarterly, significant change and annual assessments per the Resident Assessment Instrument (RAI) manual. Upon a change in condition, the comprehensive care plan or Baseline Care Plan will be updated, or an Instant Care Plan will be initiated if applicable. Review of Resident #1's comprehensive care plan, revealed, the incident that occurred on [DATE] of chasing staff around the facility, sexually inappropriate behavior and impulsivity had not been care planned, nor interventions put into place on his existing behavior care plans to address these behaviors. Review of Resident #1's Departmental Notes, and Behavior/Pain Medication Monitoring Summaries indicated no mention of the incident recorded on the Psychiatric NP's progress note on [DATE] in which Resident #1 was said to be chasing staff around the facility, being sexually inappropriate, and impulsive. During an interview, with the Minimum Data Set (MDS) Coordinator/Care Plan Nurse, on [DATE] at 12:20 PM, she verified there was no care plan for Resident #1 being sexually inappropriate, chasing staff or being impulsive. She stated that she was unaware of those behaviors occurring, she had not been told by staff, and had not read the progress note where those behaviors were mentioned. She revealed there were care plans for his other behavioral issues, however, none of them mentioned his behaviors from [DATE]. She stated that each department was responsible for creating and revising their own care plans. She stated a behavior care plan should have been started by Social Services after the incident and revised as needed. During an interview, with the Social Service Director (SSD) for the South Unit, on [DATE] at 12:48 PM, he indicated that he had been made aware of the sexual assault of Resident #2 by Resident #1 on [DATE]. He stated he was not made aware of the behaviors recorded on the progress note from [DATE], and due to that, they were not care planned. He stated the normal routine for a progress note was for the charge nurse to receive them when they arrive at the facility, read over them and then notify the appropriate departments as needed of the information within them. He feels the note didn't get read and was just filed into the chart without notification of any departments. The SSD did indicate Resident #1 had a significant history of being physically aggressive with other residents on several occasions, and with staff in resisting care, and he had multiple care plans to address his aggressive behaviors, and his medications were tracked for gradual dose reductions, however, there was no formal behavior management program for him. When asked by the State Agency (SA) what interventions were put into place after each of Resident #1's aggressive physical altercations with other residents, he stated, they would separate him from the other resident, and usually sent him out to the psychiatric unit for medication adjustments. When asked by the SA if they increased the frequency in which they observed and supervised him, he stated they had him on one (1) hour checks due to his refusal to wear a wander guard and walking all over the facility, however, it was not to address his behaviors. The SSD stated that he had not seen Resident #1 be sexually inappropriate to any other residents prior to the incident of sexual assault on [DATE]. No observation of Resident #1 was obtained during the extended survey of [DATE] through [DATE]. Resident #1 had been transferred to a Geri-psych unit on [DATE]. The facility submitted a Removal Plan for the IJ. Review of the Removal Plan revealed the facility took the following actions to remove the IJ: The ED called an emergency QAPI-QA meeting, on [DATE] at 3:15 PM, to discuss IJ's called during a complaint investigation. In attendance at the emergency QAPI-QA meeting was the ED, DON, Registered nurse (RN), RN Supervisor, and vice president of Tara Cares. Attendance by phone was the Social Service Director (SSD), Medical Director (MD), and Psychiatric Nurse Practitioner. Topics of discussion during the meeting were the aforementioned allegation of resident to resident abuse. Policy review was performed on Abuse /Neglect, Behavior management, Care plan development and implementation, monitoring and supervision of wandering residents, notification of incidents to Mississippi State Department of Health with no revisions needed. A protocol was implemented for review of physician progress notes [REDACTED]. Also discussed was the auditing charts for all residents with sexual behavior, care plans, wandering and interviewed all residents and staff for any reports of sexual abuse. 1. To meet the immediate need of Resident #2, staff assessed for any injury at the facility, and was transferred to the hospital to be evaluated by a physician. Resident #2 was provided emotional support post incident by the SSD on [DATE], was added to acute charting starting [DATE] indicative of nurses' monitoring and Resident # 2 was assessed by NP on [DATE] after returning to the facility with no negative findings. 2. Resident # 1 was immediately placed on 1:1 surveillance by a staff member until he was transported to a Geri-psych. Resident # 1 was then discharged from the facility with his family on [DATE]. 3. On [DATE] at 4:20 AM, the DON notified Mississippi State Department of Health of the incident. [DATE] at 12:50 AM, the EMS notified the local police department of the incident. Police arrived at facility with EMS and investigated incident. On [DATE] at 3:46 PM the ED submitted the final investigation to the Attorney General's Office. 4. An in service was initiated, on [DATE] at 3:00 PM, by the DON for all staff present in the building on abuse and neglect, monitoring and supervision of residents and care plan implementation and development. In service to include reporting changes in behaviors for wandering residents who exhibit aggressive behaviors immediately to the Charge Nurse and initiating interventions. The Charge Nurse will communicate with the DON or RN Supervisor to determine the frequency of increased supervision based on the assessment of the residents. All staff will be in serviced prior to working the next shift. In-service was completed on 61 of 109 staff. 5. On [DATE] at 5:00 PM an in service was conducted by the Regional Clinical Operations Nurse for the ED and DON to ensure reporting abuse allegations no later than 2 hours to regulatory agencies. The remaining department heads will be in service on next the scheduled shift. 6. On [DATE] at 3:00 PM, the ED completed 100 % audit for residents who exhibited wandering to determine any negative behavior that could be potentially harmful to other residents. Results were that 9 of 9 records reviewed and 0 found to wander and exhibit behaviors that were potentially harmful to others. 7. On [DATE], the ED completed interviews with all cognitive residents to identify any reports of sexual inappropriate conduct. Results were 25 of 25 residents interviewed and all responded No. 8. On [DATE] at 4:30 PM, the ED and DON completed a 100% chart audit on residents for review of care plans on all residents to identify residents with exhibited sexual behaviors. Results of the audit was 11 of 105 residents were noted with sexual behaviors and none were directed towards other residents. Results were 105 of 105 of charts audited had appropriate interventions in place. 9. On [DATE] at 4:30 PM, the ED and DON audited 100% of active medical records' psych progress to determine if any implementations were warranted. No issues were identified, or implementations warranted of 105 of 105 records reviewed. The facility alleges that all corrective actions to remove the Immediate Jeopardy identified on [DATE] was completed as of [DATE] at 3:30 PM, for removal of the Immediate Jeopardy (IJ) on [DATE]. On [DATE] the SA validated through staff interview, resident interview, record review, and in-service reviews that the facility had implemented the following measures to remove the IJ: 1. The SA validated through record review, Resident #2 was assessed at the facility, sent to the emergency room , has a care plan for emotional support from Social Services, and was assessed upon her return to the facility by the NP. 2. The SA validated through record review and staff interview, Resident #1 was placed on 1:1 until his transport to a Geri-psych unit. He was discharged from the facility on [DATE]. 3. The SA validated through record review and staff interview the reporting of the incident to the State Department of Health, EMS and Police Department notification, and a final investigation was sent to the Department of Health on [DATE]. 4. The SA validated through in-service sign in review, content review, and staff interview that an in-service was held for staff for all topics aforementioned on [DATE] at 3:00 PM. 5. The SA validated through in-service sign in sheet and content review, as well as staff interview, an in-service was held with administration on timely reporting as of [DATE] at 5:00 PM. 6. The SA validated through record review and staff interview the completion of an audit of care plans for resident who wander and have aggressive behaviors. No issues were found during the audit. 7. The SA validated through resident interviews and staff interviews, all cognitively aware residents were interviewed regarding inappropriate sexual conduct and 25 of 25 stated it had not occurred. 8. The SA validated through record review and staff interview a 100% chart audit for residents exhibiting sexual behaviors was completed, and none have behaviors directed at other residents. 9. The SA validated through record review and staff interview a 100% chart audit of psychiatric progress notes was completed and none were found with issues that needed addressed, or implementation of new orders. The SA validated on [DATE], that all corrective actions had been taken by the facility to remove the IJ during the survey on [DATE]. The IJ was removed on [DATE].

The State Agency (SA) conducted a Complaint Survey for CI MS # , on 07/08/2020 through 07/09/2020, and substantiated CI MS # related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 06/14/2020 at approximately 3:00 to 3:10 AM. Resident #1 was missing, unsupervised and away from the facility for approximately 20 to 35 minutes. The facility staff was not aware of Resident #1's absence until he was discovered in the parking lot of a local business by a store employee, who notified the facility of Resident #1's whereabouts at 3:30 AM. Resident #1 was returned to the facility at 3:45 AM by the Sheriff's Department. Resident #1 was assessed for any signs and symptoms of injury and pain, which was negative. Resident #1 was found fully clothed. The facility's immediate investigation revealed Resident #1 stated he had pulled the wanderguard wiring on the kitchen exit door and exited from there, but the investigation found it was the dining room door Resident #1 pulled the wiring and therefore not allowing the door to alarm. Resident #1 was placed on one to one (1:1) supervision from the time of his return until 1:00 PM on 6/14/2020 when he was transferred to a behavioral facility. The facility failed to provide adequate staff supervision which resulted in Resident #1's elopement from the facility at approximately 3:00 AM to 3:10 AM on 06/14/2020. Resident #1 was identified by the facility on his admission, 09/15/2017 for wandering behavior. A wanderguard was used for a time due to his wandering and pacing behavior day and night, exit seeking behavior and pushing on doors. The Interdisciplinary Team (IDT) determined Resident #1 was no longer an elopement risk, on 03/12/2019, because he no longer was exhibiting exit seeking behavior or pushing on doors. However, Resident #1 did continue the wandering and pacing day and night. The wandering and pacing behavior day and night was confirmed by staff interviews. Resident #1's Care Plan, dated 10/09/2017, identified Resident #1's wandering behavior, but did not address how the staff was to monitor him to prevent the possibility of elopement. During the survey, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) was identified on 07/08/20, which occurred on 06/14/2020 and existed at: 42 CFR(s): 483.25(d)(1)(2)-Free of Accidents, Hazards/Supervision/devices (F689). The facility's failure to provide adequate staff supervision for Resident #1, with a history of elopement risk and current display of wandering behavior, placed this resident and other residents who exhibit wandering behavior and at risk for elopement risk a likelihood for serious injury, harm, impairment or death. Based on the facility's implementation of corrective actions on 06/14/2020, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed as of 06/15/2020, prior to the SA's first entrance on 07/08/2020. The SA notified the facility's Administrator of the PNC IJ and SQC on 07/08/2020 at 3:30 PM. At the time of the survey, the facility had a census of 113, and held a license of 120 beds. Based on staff and resident interviews, record review and facility policy review, the facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility, on 06/14/2020 at approximately 3:00 to 3:10 AM. Resident #1 exhibited wandering and pacing behavior day and night per staff interviews prior to the incident and yet the facility did not initiate any specific monitoring for staff to follow and possibly prevent an elopement. The facility staff did not know Resident #1 was off the facility grounds until the store employee called to notify them. This concern was identified for one of four (1 of 4) residents reviewed for wandering behavior and risk for elopement. Findings include: Review of the facility's policy, Missing Resident/Elopements, dated, July 2018, revealed, The Unit Charge Nurse is responsible for knowing the location of their residents. Post survey, the facility's Administrator provided by an email statement, dated 7/30/2020 at 8:09 PM, that revealed the facility did not have a policy for supervision. Review of the facility's policy, Behavior Management and Psycho-pharmacological Medication Monitoring Program, reviewed/revised 03/18 (March 2018), revealed, Residents with behaviors that are displayed routinely, that effect the resident's psychological well-being or that of other residents, or behaviors that can have potential for harm to self or others will be assessed with [REDACTED]. The policy further revealed, The Interdisciplinary Team (IDT) will update the care plan to include the problem behavior, goals, and approaches. The planned interventions, for each individual resident's behavior will be communicated to the appropriate staff members. Interventions and response will be documented. Review of the facility's Resident Incident Report, dated 06/14/2020 at 3:45 AM, revealed the type of incident was Resident #1 wandered off the facility grounds. Resident #1 was returned to the facility at approximately 4:00 AM. No injuries or complaints of pain. Resident stated he was trying to get home to (Name of City). Resident #1 was immediately placed on one on one (1:1) monitoring with staff. The Medical Doctor (MD) was notified. Resident #1 is his own Representative Person (RP). Review of the facility's Supervisor Investigation Summary Form, dated and signed by the Administrator on 06/16/2020, revealed on June 14, 2020 at 3:30 AM, (Name of Business Manage) came in to report resident was at (Name of Business) . The facility's Dr. Wander (the facility's wandering/elopement procedure) was initiated for resident. Resident #1 was safely returned to the facility by the Sheriff's Department. Resident reported he exited facility through the dining room door by disarming the wander guard system. He stated he snatched it lose and the door opened. Resident said he was trying to get home to (Name of City). An immediate assessment by Licensed Practical Nurse (LPN) #4 was completed and revealed no injuries or pain. Resident was not on wandering monitoring prior to incident and was not at risk for elopement. Resident has no elopement attempts. Follow Up Actions: Resident #1 was admitted to the facility, on 09/15/2017, with [DIAGNOSES REDACTED]. Resident #1 was immediately assessed and placed on 1:1 monitoring. The Administrator's interview with Resident #1 revealed he stated he went out the kitchen door, however, upon investigation the kitchen door was locked and exit secure and the wires were found to be torn lose on the dining room door. Resident #1 then stated he went through the dining room door by snatching the wires and the door opened. Resident stated he was sorry for his behavior. Resident said he walked through the wooded/grass area behind the facility and continued walking to (Name of Business) trying to get a ride. Administrator interviews with the staff on duty at the time of the incident revealed Resident #1 was last seen at 3:00 AM in the dayroom. Staff also reported resident was walking in the halls on and off, and that Resident #1 was usually up at night in the day room watching television or walking off and on in the hall. (Due to COVID-19, Resident #1 was only able to ambulate on his unit, the dayroom and dining room). New Interventions-Keypad lock was placed on dining room doors per Maintenance on, 06/15/2020. The Wanderguard system at the dining room door was repaired by the Maintenance Director on 06/14/2020. Resident #1 was added to wander and elopement with monitoring of whereabouts every hour upon return to facility. The Mississippi State Department of Health was notified, on 06/14/2020 by the Administrator. After investigation, interview with the resident and staff revealed the resident was very knowledgeable and aware of his actions and able to exit the facility. The Post-Incident Actions, revealed, Resident safely returned to the facility at Approximately 4:00 AM. No injuries noted. No complaint of pain noted. Resident stated that he was trying to get home to (Name of City). Immediately placed on one to one monitoring with staff. Medical Director notified. Resident is own Responsible Party (RP). Review of the facility's staff handwritten statements revealed: Certified Nursing Assistant (CNA) #1 stated she last placed her eyes on Resident #1 in the dayroom at 3:00 AM on 06/14/2020. CNA #2 stated herself, CNAs #1 and #4, Resident #1 and another staff member were sitting in the dayroom. Then she and CNA #1 left to go assist another resident and returned to the dayroom in about 15 minutes. CNA #2 and #1 left the dayroom again about 3:00 AM to 3:10 AM to go care for another resident. CNA #2 reported Resident #1, CNA #4 and the other staff member was still in the dayroom. CNA #3 reported the last time she saw Resident #1 was at 11:30 PM, when she arrived to work. CNA #4 reported she saw Resident #1 at 2:30 AM in the dayroom, he got up and left out and she did not see him again. Licensed Practical Nurse (LPN) #4 stated she observed Resident #1 walking the halls at 11:44 PM. LPN #1/Charge Nurse Night Shift stated she observed Resident #1 at the snack machine at 1:30 AM. No exit behavior was observed. On 07/08/2020 from 12:00 PM until 12:30 PM, an observation revealed Resident #1 was ambulatory throughout the south hallway with a fast pace. Resident #1 walks back and forth, up and down the hallways of the south unit. Resident #1 stopped to sit in a chair in the hallway for several minutes and then is up pacing down the hallway again. Resident #1 is observed to have a wander guard on his wrist. On 07/08/2020 at 12:00 PM, an interview with Resident #1 revealed he was confused to date and time and he recalled the elopement when he was asked and stated, I was trying to get to (Name of City) to go and see my family. I'm not gonna try and leave again. Continued conversation with the resident indicated that he could not hold focus and attempted to hug SA surveyor several times and talked about how the door just popped open when he pulled the wires around the door. During an interview, on 07/08/2020 at 3:15 PM, Licensed Practical Nurse (LPN) # 1, who was the night shift supervisor on 06/14/2020, revealed the last time she saw Resident #1 was around 2:30 AM that morning and he was in the dayroom. LPN #1 stated Resident #1 stays up late and watches television in the dayroom and he walks the halls constantly. LPN #1 stated she was the one who received the call from the business employee who reported Resident #1 wandering in the store's parking lot. LPN #1 reported the store employee said he was one of our residents and she guessed he must have told the store employee he was a resident here. LPN #1 said she called the Administrator and she came to the facility right away. LPN #1 revealed Resident #1 was not on any type supervision prior to that night. LPN #1 reported Resident #1 was sent to the behavioral unit on 06/14/2020 and returned to the facility on [DATE] with orders for a wanderguard and to check him every hour for his location and check the wanderguard every shift. An interview, on 07/08/2020 at 4:00 PM, with Certified Nursing Assistant (CNA) #1 revealed the last time she saw Resident #1, on 06/14/2020, was at 3:00 AM in the dayroom. CNA #1 reported Resident #1 walked the hall and to the dayroom at night. CNA #1 said this was how Resident #1 was at night. He used to go to the doors and push on the handles, but no longer does that, and hasn't in a while. CNA #1 stated Resident #1 was not on any specific supervision prior to his leaving the facility that night. CNA #1 confirmed they did not know Resident #1 was gone or his whereabouts until that (Name of Business) employee called LPN #1 to report him wandering in their parking lot. CNA #1 reported Resident #1 was sent to a behavioral hospital after that night, and did come back to the facility a week or so later. CNA #1 also said the resident is wearing a wanderguard now and his whereabouts is checked every hour. An interview, on 07/08/2020 at 4:40 PM, with CNA #2 revealed the last time she saw Resident #1, on 06/14/2020 was about 3:00 to 3:10 AM. CNA #2 stated the same information as her written statement that CNA #1, CNA #4, Resident #1 and another staff member were sitting in the dayroom. Then she and CNA #1 left to go assist another resident and returned to the dayroom in about 15 minutes. CNA #2 and #1 left the dayroom again about 3:00 AM to 3:10 AM to go care for another resident. CNA #2 reported Resident #1, CNA #4 and the other staff member was still in the dayroom. CNA #2 stated Resident #1 was not on any special supervision, and he did walk the hall and go to the dayroom pretty much all night, this was nothing different. CNA #2 said he used to go to the doors, push on the handles, but has not that in a while. CNA #2 said they did not know Resident #1 had left the building that night. CNA #2 said they did not know where he was until the store employee called and told the charge nurse. A review of Resident #1's Behavior/Intervention Monthly Flow Record, dated May 2020 and June 1st to the 14th, revealed wandering behavior was not addressed. Wandering behavior was added on 06/22/2020, the date Resident #1 returned from the behavioral unit. Resident #1 was admitted to a behavioral unit on 06/14/2020. Review of Resident #1's Psychological Evaluation, dated 03/26/2020, revealed [DIAGNOSES REDACTED]. The Behavior/Symptoms included: false accusation, easily agitated, verbal/physical aggressiveness, manipulative, wandering in other resident rooms/stealing, and socially inappropriate language. The evaluation further stated, will continue plan of care, will review in 30 days. Follow Up Date: 04/02/2020-No behaviors noted, will continue plan of care. Will review in 30 days. Follow Up Date: 05/14/2020-No behaviors noted/observed, no exit seeking behavior. Will continue with plan of care and review in 30 days. Review of Resident #1's Risk of Elopement Evaluation, dated 08/30/2019 and signed by the Director of Nurses (DON), revealed Resident #1 was not at risk for elopement. The form had review dates of, 11/29/2019, 02/28/2020 and 05/27/2020. The Risk of Elopement Evaluation, dated 06/22/2020, stated Resident #1 was at risk for elopement, he had a past history of leaving the facility and ambulates independently. Visual checks are to be done hourly. Review of Resident #1's Admission/Re-Admission Evaluation, dated 09/15/2017, signed by the Director of Nurses (DON), revealed Resident #1 ambulated independently and had a history of [REDACTED].#1 was his own designated Representative Person (RP). During an interview, on 07/08/2020 at 1:50 PM, the Social Services Director (SSD), stated Resident #1 was previously an elopement risk when he was admitted , on 09/15/2017, because he did just what he does now and wandered and paced, but after we saw that was just what he did and he wasn't trying to leave the building we discontinued it. The SSD stated he wasn't sure when the elopement monitoring had been discontinued and did confirm Resident #1 was not monitored for an elopement risk when he eloped on 06/14/2020 and that he did not have a wanderguard on at that time. The SSD confirmed Resident #1 was assessed on 06/14/2020 and marked as an elopement risk after he was returned to the building by the local police. The SSD stated Resident #1 now has a wander guard to his wrist and is monitored every hour for his presence. Review of the Departmental Notes, Social Services, dated 03/12/2019, revealed the Interdisciplinary Team (IDT) members evaluated Resident #1 for risk of elopement. Resident is no longer at risk for elopement due to no longer exhibiting exit seeking behaviors, such as wandering aimlessly or pushing on exit door handles. Resident has not exhibited any wandering/exit seeking behaviors in the past year. Resident is alert to person, time and place. An interview with the Administrator, on 07/08/2020 at 11:30 AM, revealed Resident #1 had indicated to the staff which door he had went out of when he left the building. The Administrator stated they checked the dining room door and it was closed, but not secured because he had torn the wires. The Administrator said she called the Maintenance Director to the building right away and he fixed the fire door to secure it again. The Administrator reported Resident #1was placed on one on one (1:1) supervision to prevent further elopements and was care planned for elopement after that incident. The Administrator stated Resident #1 was sent for a behavior evaluation that same day. During an interview with the Maintenance Director, on 07/08/2020 at 2:55 PM, he confirmed he arrived at the facility shortly after 4:00 AM to repair the door. The Maintenance Director stated the dining room door was closed, but not secured because the resident had pulled the wires out of the wanderguard system and it had disarmed the magnet system that keeps the door locked and secured. The Maintenance Director stated he built boxes around all of the wanderguard wires. The Maintenance Director stated the doors are checked daily. Review of the facility's Educational In-Service Record, dated 06/14/2020, revealed the facility provided all the staff an in-service on elopement which included following orders for visual checks/monitoring resident location, function of wanderguard per orders, answering alarms in a timely manner, and door/wanderguard alarms. An interview, on 07/09/2020 at 12:10 PM, with the Medicaid Nurse revealed, He walks constantly but he doesn't push on the doors like he did when he was first admitted . Social Services did update his care plan. Before COVID, he would walk throughout his hallway, the dining room and would sit up front at the front entrance and look out the door. But, now because of the isolation, residents are not allowed to go to the dining room or throughout the building. The Medicaid Nurse confirmed that the isolation has changed a lot of the resident's normal behaviors. An interview and observation of the facility's layout, at 11:30 AM on 07/08/2020, with the Administrator, revealed the south and north hallways have the double doors closed leading to the residents rooms to prevent further spread of COVID. Resident #1 is located on the south hall and in the morning hours of 06/14/2020 at 3:00 AM, Resident #1 walked through the closed double doors into the open foyer area, and into the dining room and then made his way to the fire exit door at the back of the dining room and pulled the wiring on the door until it was disconnected and it opened. The resident then walked through an outside storage building which is in close proximity to the dining room fire door and exited the back of the storage shed which housed equipment. Staff were not aware that Resident #1 was outside of the south hall unit and records revealed that staff were not aware the resident was even out of the building until they received a call from a local business that the resident was in their parking lot. The facility investigation was unable to conclude his path that was taken that caused him to arrive in the parking lot of a local business and was discovered there by an employee. The facility Administrator confirmed that the facility does not have cameras inside the building or on the outside of the building that would have confirmed the exact path of the resident. It was determined the distance from the facility to the (Name of Business) is 1.4 miles. On 07/08/2020 at 12:10 PM, an interview with a Housekeeping staff member on the hall revealed Resident #1 walking constantly. An interview with the Activity Director, on 07/08/2020 12:15 PM, revealed, He walks constantly, it's hard to get him to sit down for activities. During an in interview with Licensed Practical Nurse Supervisor (LPN) #2/Day Shift Supervisor, on 07/08/2020 at 12:20 PM stated, That's his normal, he paces all the time, he doesn't sit for very long. During an interview with the Administrator and the Director of Nursing (DON), on 07/08/2020 at 3:30 PM, they confirmed that Resident #1 was an elopement risk on admission in 2017, and he was taken off as an elopement risk in March 2019 and the wanderguard was discontinued. The Administrator and DON stated, He was doing good, we assess him every quarter. When he first came in the facility, he did walk constantly so we used a wanderguard until March 2019 and then we decided to take it off because he had not went to the door and attempted to exit, he just walked around the facility. Review of Resident #1's June and July 2020 Physician's Orders did not reveal an order to monitor Resident #1's wandering behavior. Review of the Face sheet revealed Resident #1 was admitted by the facility, on 09/15/2017 with a history of Mood Disorder, Major [MEDICAL CONDITIONS], Dementia, Kleptomania, Impulse Disorder and [MEDICAL CONDITION]. Review of a Quarterly MDS, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate to severe cognitive impairment. Further review of the MDS revealed Resident #1's Section D. Mood was checked never or one (1) day for feeling down, depressed, little sleep, tired/no energy, trouble concentrating, slow, fidgety and restless. Section E. Behavior was checked for none of the above, indicating no psychotic hallucinations and/or delusions. The behaviors for physical and verbal behavior symptoms directed toward others, other behavior symptoms not directed toward others, rejection of care and wandering were checked as behavior not exhibited. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions prior to the State Agency (SA) entrance on 07/08/20. In Response to the Past Noncompliance IJ and SQC cited at 3:30 PM on 07/08/20, the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility to remove the IJ. Description of Incident: On June 14, 2020 around 3:30 AM the facility LPN Charge Nurse received a phone call from a local business that a resident was in their parking lot. The LPN Charge Nurse verified that the resident was from their facility. The facility immediately initiated the facility wide elopement protocol. The local sheriff's department staff was at the business and returned the resident back to the facility at 4:00 AM. Upon return to the facility on [DATE] at 4:00 AM Resident #1 was evaluated for injuries by the LPN Charge Nurse. Resident #1 did not complain of any pain or injuries, nor were there any injuries noted upon evaluation of resident. Resident #1 is his own responsible representative (RR). The facility Registered Nurse (RN) #1 completed an elopement audit of Resident #1 on 6/14/2020. Based on Resident #1's earlier decision to disarm the dining room door and exit the facility, the facility deemed elopement precautions were necessary. The facility staff immediately placed Resident #1 on one on one monitoring on his return to the facility at 4:00 AM until resident was later transferred to a behavior unit on 6/14/2020 at 1:30 PM. On 6/14/2020 an immediate head count of all residents was completed by facility staff nurses LPN #1, LPN #3 and LPN #4. The results of the facility head count of all residents revealed that all residents (100%) were present and accounted for in the facility. Resident #1's physician and facility medical director, was notified on 6/14/2020 that Resident #1 had disarmed the dining room door by ripping out the doors wander guard wiring. The Medical Director physician ordered to admit to behavior unit. On 6/14/2020 the Director of Nursing (DON) initiated an in-service to facility staff on resident wandering, elopement, and supervision. No staff will be allowed to return to work until in-service was complete. 8 RNs 17LPNs, 50 CNAs, 16 dietary, 10 housekeeping/laundry, 2 activities, 2 maintenance, 1 medical record, 2 business office, 2 social, 1 admissions. On 6/14/2020 the Administrator initiated staff interviews regarding the incident of Resident #1's exit of the facility. These staff interviews revealed that Resident #1 was last seen by facility staff between the hours of 3:00 AM and 3:10 AM. The State Agency was immediately notified of incident on 6/14/2020. A completed investigation was faxed on 6/16/2020. All residents were evaluated for wander, elopement, and supervision risk 6/14/2020 by the facility social worker. The evaluation results revealed no wander, elopement, and supervision changes were necessary at that time. On 6/14/2020 the facility social worker reviewed the elopement books. This review revealed that the elopement books were up to date appropriately placed, and did not require any needed changes. An elopement drill was initiated on 6/14/2020 by the social service department. The elopement drill was conducted with staff participation, appropriate response, and no issues noted. Prior elopement drills had been conducted on 5/26/2020. On 6/14/2020 the wander guard system at the dining room exit door was immediately repaired by the Maintenance Director. The facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance (QA) meeting on June 14, 2020. The QA team discussed that Resident #1 had never since admission left the facility unsupervised there was a need to to monitor resident #1's whereabouts with a wander bracelet and supervision due to the elopement, whereby reevaluation would be conducted at the next quarterly QA meeting. The QA team also concurred that sending resident to the behavior unit had been appropriate. The QA team did not suggest any additional interventions at that time. Upon return from the behavior unit on 06/22/20, Resident #1 wander assessment was updated upon readmission. Resident #1's plan of care was updated on readmission on 06/22/20 to include elopement monitoring of Resident #1 every hour with wander bracelet. Review on 6/14/2020 of Resident #1's medical record conducted by the DON as part of the QA process revealed resident had been evaluated for elopement quarterly with no risk for elopement with last evaluations completed 8/30/2019, 11/29/2019, 2/28/2020, and 5/27/2020. The facility corrective actions were initiated on 6/14/2020. All activities to remove IJ was initiated on 6/14/2020 and completed on 6/15/2020. The facility alleges the IJ was removed on 6/15/2020. The SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interview. The SA validated through record review and interview that Resident #1 was evaluated for injuries by the LPN Charge Nurse. Resident #1 did not complain of any pain or injuries, nor were there any injuries noted upon evaluation of resident. Resident #1 is his own responsible representative (RR). The SA validated through record review that an elopement audit of Resident #1 on 6/14/2020. Based on Resident #1's earlier decision to disarm the dining room door and exit the facility, the facility deemed elopement precautions were necessary. The SA validated through record review that the facility staff immediately placed Resident #1 on one on one monitoring on his return to the facility at 4:00 AM until resident was later transferred to a behavior unit on 6/14/2020 at 1:30 PM. The SA validated through record review and interview that on 6/14/2020 an immediate head count of all residents was completed by facility staff nurses LPN #1, LPN #3 and LPN #4. The results of the facility head count of all residents revealed that all residents (100%) were present and accounted for in the facility. The SA validated through interview that Resident #1's physician and facility medical director, was notified on 6/14/2020 that Resident #1 had disarmed the dining room door by ripping out the doors wander guard wiring. The Medical Director physician ordered to admit to behavior unit. The SA validated through record review and interviews that on 6/14/2020 the Director of Nursing (DON) initiated an in-service to facility staff on resident wandering, elopement, and supervision. No staff will be allowed to return to work until in-service was complete. 8 RNs 17 LPNs, 50 CNAs, 16 dietary, 10 housekeeping/laundry, 2 activities, 2 maintenance, 1 medical record, 2 business office, 2 social, 1 admissions. The SA validated that on 6/14/2020 the Administrator initiated staff interviews regarding the incident of Resident #1 exit of the facility. These staff interviews revealed that Resident #1 was last seen by facility staff between the hours of 3:00 AM and 3:10 AM. The SA validated through record review that The State Agency was immediately notified of incident on 6/14/2020. A completed investigation was faxed on 6/16/2020. The SA validated through record review and interviews that all residents were evaluated for wander, elopement, and supervision risk 6/14/2020 by the facility social worker. The evaluation results revealed no wander, elopement, and supervision changes were necessary at that time. The SA validated that on 6/14/2020 the facility social worker reviewed the elopement books. This review revealed that the elopement books were up to date appropriately placed, and did not require any needed changes. The SA validated through record review and interviews that an elopement drill was initiated on 6/14/2020 by the social service department. The elopement drill was conducted with staff participation, appropriate response, and no issues noted. Prior elopement drills had been conducted on 5/26/2020. The SA validated through observation and record review that on 6/14/2020 the wander guard system at the dining room exit door was immediately repaired by the Maintenance Director. The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance (QA) meeting on June 14, 2020. The QA team discussed that Resident #1 had never since admission left the facility unsupervised there was a need to to monitor resident #1's whereabouts with a wander bracelet and supervision due to the elopement, whereby reevaluation would be conducted at the next quarterly QA meeting. The QA team also concurred that sending resident to the behavior unit had been appropriate. The QA team did not suggest any additional interventions at that time. The SA validated through observation and record review that upon return from the behavior unit on 06/22/20, Resident #1 wander/elopement assessment was updated and a wanderguard was placed on Resident #1 on his admission back into the facility. The SA validated through record review and interview that Resident #1's plan of care was updated on readmission on 06/22/20 to include elopement monitoring of resident every hour with wander bracelet.

The State Agency (SA) conducted a Complaint Survey for CI MS # on 07/08/2020 through 07/09/2020 and substantiated CI MS # related to an elopement, when the facility failed to provide adequate supervision to prevent Resident #1's elopement from the facility on 06/14/2020 at approximately 3:00 AM to 3:10 AM. Resident #1 was missing, unsupervised and away from the facility for approximately 20 to 35 minutes. The facility staff was not aware of Resident #1's absence until he was discovered in the parking lot of a local business by a store employee, who notified the facility of Resident #1's whereabouts at 3:30 AM. Resident #1 was returned to the facility at 3:45 AM by the Sheriff's Department. Resident #1 was assessed for any signs and symptoms of injury and pain, which was negative. Resident #1 was found fully clothed. The facility's immediate investigation revealed Resident #1 stated he had pulled the wanderguard wiring on the kitchen exit door and exited from there, but the investigation found it was the dining room door Resident #1 pulled the wiring and therefore not allowing the door to alarm. Resident #1 was placed on one to one (1:1) supervision from the time of his return until 1:00 PM on 6/14/2020 when he was transferred to a behavioral facility. The facility failed to develop and implement a care plan for Resident #1 to prevent the possibility of elopement. Resident #1 was identified by the facility on his admission, 09/15/2017 for wandering behavior. A wanderguard was used for a time due to his wandering and pacing behavior day and night, exit seeking behavior and pushing on doors. The Interdisciplinary Team (IDT) determined Resident #1 was no longer an elopement risk on 03/12/2019 because he no longer was exhibiting exit seeking behavior or pushing on doors. However, Resident #1 did continue the wandering and pacing day and night. The wandering and pacing behavior day and night was confirmed by staff interviews. Resident #1's Care Plan, dated 10/09/2017, identified Resident #1's wandering behavior, but did not address how the staff was to monitor him to prevent the possibility of elopement. During the survey, the SA identified an Immediate Jeopardy (IJ) on 07/08/20, which occurred on 06/14/2020 and existed at: 42 CFR(s): 483.21(d)(1)(2)-Develop/Implement Comprehensive Care Plan (F656). The facility's failure to implement and develop a comprehensive care plan, for Resident #1 with a history of elopement risk and current wandering behavior, placed this resident and other residents who are an elopement risk and/or exhibited wandering behavior to a likely cause of serious injury, harm, impairment or death. Based on the facility's implementation of corrective actions on 06/14/2020, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed as of 06/15/2020, prior to the SA's first entrance on 07/08/2020. The SA notified the facility's Administrator of the PNC IJ 07/08/2020 at 3:30 PM. At the time of the survey, the facility had a census of 113, and held a license of 120 beds. Based on record review, staff and resident interview and facility policy review, the facility failed to develop and implement a Comprehensive Care Plan to provide Resident #1 with adequate staff supervision to prevent an elopement from the facility, for one (1) of four (4) residents reviewed for elopement risk, Resident #1. Findings include: A review of the facility's policy, Comprehensive Person Centered Care Plans, dated, March 2018, revealed, Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the team will provide care. Further review revealed, Procedure: 4. The Interdisciplinary Team along with the resident and/or Resident Representative will identify resident problems, needs, strengths, life history, preferences, and goals. 5. For each problem, need, or strength a resident-centered goal is developed. Goals should be measurable (i.e. walk from nurse's station to room by (date). 6. Staff approaches are to be developed for each problem/strength/need (including PASSARR/Preadmission Screening and Resident Review recommendations as applicable). Assigned disciplines will be identified to carry out the intervention. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan or Baseline Care Plan will be updated or an Instant Care Plan will be initiated if applicable. Review of the facility's policy, Behavior Management and Psycho-pharmacological Medication Monitoring Program, reviewed/revised 03/18 (March 2018), revealed, The Interdisciplinary Team (IDT) will update the care plan to include the problem behavior, goals, and approaches. The planned interventions, for each individual resident's behavior will be communicated to the appropriate staff members. Interventions and response will be documented. Review of Resident #1's Comprehensive Person Centered Care Plan, dated 10/09/2017, revealed the resident was on a behavior management program which included wandering. The Approaches did not include monitoring or supervising Resident #1 for his wandering and pacing behavior day and night. Review of the facility's Resident Incident Report, dated 06/14/2020 at 3:45 AM, revealed the type of incident was Resident #1 wandered off the facility grounds. Resident #1 was returned to the facility at approximately 4:00 AM. No injuries or complaints of pain. Resident stated he was trying to get home to (Name of City). Resident #1 was immediately placed on one on one (1:1) monitoring with staff. The Medical Doctor (MD) was notified. Resident #1 is his own Representative Person (RP). Review of the facility's Supervisor Investigation Summary Form, dated and signed by the Administrator on 06/16/2020, revealed on June 14, 2020 at 3:30 AM, (Name of Business Manage) came in to report resident was at (Name of Business) . The facility's Dr. Wander (the facility's wandering/elopement procedure) was initiated for resident. Resident #1 was safely returned to the facility by the Sheriff's Department. Resident reported he exited facility through the dining room door by disarming the wander guard system. He stated he snatched it lose and the door opened. Resident said he was trying to get home to (Name of City). An immediate assessment by Licensed Practical Nurse (LPN) #4 was completed and revealed no injuries or pain. Resident was not on wandering monitoring prior to incident and was not at risk for elopement. Resident has no elopement attempts. Follow Up Actions: Resident #1 was admitted to the facility, on 09/15/2017, with [DIAGNOSES REDACTED]. Resident #1 was immediately assessed and placed on 1:1 monitoring. The Administrator's interview with Resident #1 revealed he stated he went out the kitchen door, however, upon investigation the kitchen door was locked and exit secure and the wires were found to be torn lose on the dining room door. Resident #1 then stated he went through the dining room door by snatching the wires and the door opened. Resident stated he was sorry for his behavior. Resident said he walked through the wooded/grass area behind the facility and continued walking to (Name of Business) trying to get a ride. Administrator interviews with the staff on duty at the time of the incident revealed Resident #1 was last seen at 3:00 AM in the dayroom. Staff also reported resident was walking in the halls on and off, and that Resident #1 was usually up at night in the day room watching television or walking off and on in the hall. (Due to COVID-19, Resident #1 was only able to ambulate on his unit, the dayroom and dining room). New Interventions-Keypad lock was placed on dining room doors per Maintenance on, 06/15/2020. The Wanderguard system at dining room door was repaired by the Maintenance Director on 06/14/2020. Resident #1 was added to wander and elopement with monitoring of whereabouts every hour upon return to facility. The Mississippi State Department of Health was notified, on 06/14/2020 by the Administrator. After investigation, interview with the resident and staff revealed the resident was very knowledgeable and aware of his actions and able to exit the facility. An observation, on 07/08/2020 from 12:00 PM until 12:30 PM, revealed Resident #1 ambulatory throughout the south hallway with a fast pace. Resident #1 walks back and forth, up and down the hallways of the south unit. Resident #1 stopped to sit in a chair in the hallway for several minutes and then is up pacing down the hallway again. Resident #1 was observed to have a wander guard on his wrist. An interview, on 07/08/2020 at 12:00 PM, with Resident #1 revealed he was confused to date and time and he recalled the elopement when he was asked and stated, I was trying to get to (Name of City) to go and see my family. I'm not gonna try and leave again. Continued conversation with the resident indicated that he could not hold focus and attempted to hug SA surveyor several times and talked about how the door just popped open when he pulled the wires around the door. An interview with Social Services Director (SSD), on 07/08/2020 at 1:50 PM, revealed Resident #1 was previously an elopement risk when he was admitted , on 09/15/17, because he did just what he does now and wandered and paced, but after we saw that was just what he did and he wasn't trying to leave the building we discontinued his care plan for elopement and wandering. The Social Services Director wasn't sure when the elopement monitoring care plan had been discontinued, but confirmed that Resident #1 was not monitored for an elopement risk prior to his elopement, on 06/14/2020. The SSD also confirmed Resident #1 did not have a wanderguard on at that time. The SSD confirmed Resident #1 was assessed on 06/14/2020 and was identified as an elopement risk after he was returned to the building by the local police. The SSD stated Resident #1 now has a wander guard on his wrist and he is monitored every hour for his presence. The SSD confirmed that he had implemented a care plan for elopement for Resident #1 on 06/14/2020. Review of a Psychological Assessment, dated 02/07/2020, revealed Resident #1 was easily agitated, manipulative, verbally and physically aggressive and wanders into other (resident) rooms stealing. Record review of Departmental Notes, dated 03/12/19 stated, Interdisciplinary Team (IDT) members evaluated resident for risk of elopement. Resident is no longer at risk for elopement d/t (due to) no longer exhibiting exit seeking behaviors, such as wandering aimlessly or pushing on exit door handles. Resident has not exhibited any wandering/exit seeking behaviors in the past year. Review of the facility's Elopement Audit, dated 06/15/2020, revealed seven (7) resident names on the list, Resident #1's name was not on the list. Review of the facility's Wanderguard Tracking System, dated 06/15/2020, revealed eight (8) resident names on the list, Resident #1's name was not on the list. Review of Resident #1's Care Plan, dated 06/14/2020, revealed the Problem for Resident #1's elopement and now wears a wanderguard. The Approaches included: Staff to observe resident for elopement attempts as resident may go to the door, alert staff to resident wandering behavior, observe whereabouts of resident and redirect wandering and elopement behavior. The Care Plan, dated 06/22/2020, the day of Resident #1's return to the facility revealed checking the wanderguard function every shift and monitor Resident #1's whereabouts every hour. An interview, on 07/08/2020 at 12:15 PM, revealed the Activity Director stated, He walks constantly, it's hard to get him to sit down for activities. During an interview with Licensed Practical Nurse Supervisor (LPN) #2, on 07/08/2020 at 12:20 PM, she stated, That's his normal, he paces all the time, he doesn't sit for very long. Review of Resident #1's Behavior Intervention Monthly Flow Record, dated May and June, 1st through the 14th, 2020, revealed wandering behavior was not addressed. The June 2020 flow sheet began addressing wandering behavior on the 22nd, upon his return to the facility from the behavioral unit. During an interview, on 07/08/2020 at 3:15 PM, LPN #1, who was the night shift supervisor, on 06/14/2020, stated Resident #1 stays up late and watches television in the dayroom and he walks the halls constantly. LPN #1 stated, The last time I saw him was around 2:30 AM that morning and he was in the dayroom. An interview with the Administrator and the Director of Nursing (DON), on 07/08/2020 at 3:30 PM, confirmed Resident #1 was identified as an elopement risk on admission in 2017, and he was taken off as an elopement risk in March 2019 and the wanderguard was discontinued. The Administrator and DON stated, He was doing good, we assess him every quarter. When he first came in the facility, he did walk constantly so we used a wanderguard until March 2019, and then we decided to take it off because he had not went to the door and attempted to exit, he just walked around the facility. An interview with the Administrator, on 07/08/2020 at 11:30 AM, revealed Resident #1 was placed on 1:1 supervision upon return to the facility until he was transferred to the behavioral facility to prevent further elopement and was care planned for the elopement. During an interview, on 07/09/2020 at 12:10 PM, the Medicaid Nurse stated, He walks constantly but he doesn't push on the doors like he did when he was first admitted . Social Services did update his care plan. Before COVID, he would walk throughout his hallway, the dining room and would sit up front at the front entrance and look out the door. But, now because of the isolation, residents are not allowed to go to the dining room or throughout the building. The Medicaid Nurse confirmed that the isolation has changed a lot of the resident's normal behaviors. An observation, interview and tour, on 07/08/2020 at 11:30 AM, of the facility with the Administrator, revealed staff was not aware that Resident #1 was outside of the south hall unit and that staff was not aware the Resident #1 was even out of the building until they received a call from a local business that the resident was in their parking lot. The south and north hallways have double doors closed leading to the residents rooms to prevent further spread of COVID. Resident #1 is located on the south hall. The Administrator explained that in the morning hours, of 06/14/2020 at 3:00 AM, Resident #1 walked through the closed double doors and into the open foyer area and walked into the dining room and made his way to the fire exit door at the back of the dining room and pulled the wiring on the door until it was disconnected and it opened. The resident then walked through an outside storage building which is in close proximity to the dining room fire door and exited the back of the storage shed which housed equipment The facility investigation was unable to conclude his path that was taken that caused him to arrive in the parking lot of a local business and was discovered there by an employee. The facility Administrator confirmed that the facility does not have cameras inside the building or on the outside of the building that would have confirmed the exact path of the resident. An interview, on 07/08/2020 at 1:30 PM, revealed the Administrator stated there was not a care plan in use for Resident #1's wandering behavior and/or elopement risk prior to this incident on 06/14/2020. Review of Resident #1's June and July 2020 Physician's Orders did not reveal an order to monitor Resident #1's wandering behavior. Review of the Face sheet revealed Resident #1 was admitted by the facility, on 09/15/2017 with a history of Mood Disorder, Major [MEDICAL CONDITIONS], Dementia, Kleptomania, Impulse Disorder and [MEDICAL CONDITION]. Review of a Quarterly MDS, dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate to severe cognitive impairment. Further review of the MDS revealed Resident #1's Section D. Mood was checked never or one (1) day for feeling down, depressed, little sleep, tired/no energy, trouble concentrating, slow, fidgety and restless. Section E. Behavior was checked for none of the above, indicating no psychotic hallucinations and/or delusions. The behaviors for physical and verbal behavior symptoms directed toward others, other behavior symptoms not directed toward others, rejection of care and wandering were checked as behavior not exhibited. The facility implemented the following Immediate Jeopardy (IJ) Removal Plan/Corrective Actions prior to the State Agency (SA) entrance on 07/08/20. In Response to the Past Noncompliance IJ and SQC cited at 3:30 PM on 07/08/20, the facility submitted a brief summary of the event, including an IJ Removal Plan and Corrective Actions, taken by the facility to remove the IJ. Description of Incident: On June 14, 2020 around 3:30 AM the facility LPN Charge Nurse received a phone call from a local business that a resident was in their parking lot. The LPN Charge Nurse verified that the resident was from their facility. The facility immediately initiated the facility wide elopement protocol. The local sheriff's department staff was at the business and returned the resident back to the facility at 4:00 AM. Upon return to the facility on [DATE] at 4:00 AM Resident #1 was evaluated for injuries by the LPN Charge Nurse. Resident #1 did not complain of any pain or injuries, nor were there any injuries noted upon evaluation of resident. Resident #1 is his own responsible representative (RR). The facility Registered Nurse (RN) #1 completed an elopement audit of Resident #1 on 6/14/2020. Based on Resident #1's earlier decision to disarm the dining room door and exit the facility, the facility deemed elopement precautions were necessary. The facility staff immediately placed Resident #1 on one on one monitoring on his return to the facility at 4:00 AM until resident was later transferred to a behavior unit on 6/14/2020 at 1:30 PM. On 6/14/2020 an immediate head count of all residents was completed by facility staff nurses LPN #1, LPN #3 and LPN #4. The results of the facility head count of all residents revealed that all residents (100%) were present and accounted for in the facility. Resident #1's physician and facility medical director, was notified on 6/14/2020 that Resident #1 had disarmed the dining room door by ripping out the doors wander guard wiring. The Medical Director physician ordered to admit to behavior unit. On 6/14/2020 the Director of Nursing (DON) initiated an in-service to facility staff on resident wandering, elopement, and supervision. No staff will be allowed to return to work until in-service was complete. 8 RNs 17LPNs, 50 CNAs, 16 dietary, 10 housekeeping/laundry, 2 activities, 2 maintenance, 1 medical record, 2 business office, 2 social, 1 admissions. On 6/14/2020 the Administrator initiated staff interviews regarding the incident of Resident #1's exit of the facility. These staff interviews revealed that Resident #1 was last seen by facility staff between the hours of 3:00 AM and 3:10 AM. The State Agency was immediately notified of incident on 6/14/2020. A completed investigation was faxed on 6/16/2020. All residents were evaluated for wander, elopement, and supervision risk 6/14/2020 by the facility social worker. The evaluation results revealed no wander, elopement, and supervision changes were necessary at that time. On 6/14/2020 the facility social worker reviewed the elopement books. This review revealed that the elopement books were up to date appropriately placed, and did not require any needed changes. An elopement drill was initiated on 6/14/2020 by the social service department. The elopement drill was conducted with staff participation, appropriate response, and no issues noted. Prior elopement drills had been conducted on 5/26/2020. On 6/14/2020 the wander guard system at the dining room exit door was immediately repaired by the Maintenance Director. The facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance (QA) meeting on June 14, 2020. The QA team discussed that Resident #1 had never since admission left the facility unsupervised there was a need to to monitor resident #1's whereabouts with a wander bracelet and supervision due to the elopement, whereby reevaluation would be conducted at the next quarterly QA meeting. The QA team also concurred that sending resident to the behavior unit had been appropriate. The QA team did not suggest any additional interventions at that time. Upon return from the behavior unit on 06/22/20, Resident #1 wander assessment was updated upon readmission. Resident #1's plan of care was updated on readmission on 06/22/20 to include elopement monitoring of Resident #1 every hour with wander bracelet. Review on 6/14/2020 of Resident #1's medical record conducted by the DON as part of the QA process revealed resident had been evaluated for elopement quarterly with no risk for elopement with last evaluations completed 8/30/2019, 11/29/2019, 2/28/2020, and 5/27/2020. The facility corrective actions were initiated on 6/14/2020. All activities to remove IJ was initiated on 6/14/2020 and completed on 6/15/2020. The facility alleges the IJ was removed on 6/15/2020. The SA validated the facility's investigation of the incident and implementation of the IJ Removal Plan/Corrective Action through observations, facility record review and interview. The SA validated through record review and interview that Resident #1 was evaluated for injuries by the LPN Charge Nurse. Resident #1 did not complain of any pain or injuries, nor were there any injuries noted upon evaluation of resident. Resident #1 is his own responsible representative (RR). The SA validated through record review that an elopement audit of Resident #1 on 6/14/2020. Based on Resident #1's earlier decision to disarm the dining room door and exit the facility, the facility deemed elopement precautions were necessary. The SA validated through record review that the facility staff immediately placed Resident #1 on one on one monitoring on his return to the facility at 4:00 AM until resident was later transferred to a behavior unit on 6/14/2020 at 1:30 PM. The SA validated through record review and interview that on 6/14/2020 an immediate head count of all residents was completed by facility staff nurses LPN #1, LPN #3 and LPN #4. The results of the facility head count of all residents revealed that all residents (100%) were present and accounted for in the facility. The SA validated through interview that Resident #1's physician and facility medical director, was notified on 6/14/2020 that Resident #1 had disarmed the dining room door by ripping out the doors wander guard wiring. The Medical Director physician ordered to admit to behavior unit. The SA validated through record review and interviews that on 6/14/2020 the Director of Nursing (DON) initiated an in-service to facility staff on resident wandering, elopement, and supervision. No staff will be allowed to return to work until in-service was complete. 8 RNs 17 LPNs, 50 CNAs, 16 dietary, 10 housekeeping/laundry, 2 activities, 2 maintenance, 1 medical record, 2 business office, 2 social, 1 admissions. The SA validated that on 6/14/2020 the Administrator initiated staff interviews regarding the incident of Resident #1 exit of the facility. These staff interviews revealed that Resident #1 was last seen by facility staff between the hours of 3:00 AM and 3:10 AM. The SA validated through record review that The State Agency was immediately notified of incident on 6/14/2020. A completed investigation was faxed on 6/16/2020. The SA validated through record review and interviews that all residents were evaluated for wander, elopement, and supervision risk 6/14/2020 by the facility social worker. The evaluation results revealed no wander, elopement, and supervision changes were necessary at that time. The SA validated that on 6/14/2020 the facility social worker reviewed the elopement books. This review revealed that the elopement books were up to date appropriately placed, and did not require any needed changes. The SA validated through record review and interviews that an elopement drill was initiated on 6/14/2020 by the social service department. The elopement drill was conducted with staff participation, appropriate response, and no issues noted. Prior elopement drills had been conducted on 5/26/2020. The SA validated through observation and record review that on 6/14/2020 the wander guard system at the dining room exit door was immediately repaired by the Maintenance Director. The SA validated through record review and interviews that the facility discussed Resident #1's incident of elopement from the facility at an emergency Quality Assurance (QA) meeting on June 14, 2020. The QA team discussed that Resident #1 had never since admission left the facility unsupervised there was a need to to monitor resident #1's whereabouts with a wander bracelet and supervision due to the elopement, whereby reevaluation would be conducted at the next quarterly QA meeting. The QA team also concurred that sending resident to the behavior unit had been appropriate. The QA team did not suggest any additional interventions at that time. The SA validated through observation and record review that upon return from the behavior unit on 06/22/20, Resident #1 wander/elopement assessment was updated and a wanderguard was placed on Resident #1 on his admission back into the facility. The SA validated through record review and interview that Resident #1's plan of care was updated on readmission on 06/22/20 to include elopement monitoring of resident every hour with wander bracelet.

Based on record review, staff interview and policy review, the facility failed to ensure that one (1) of 10 residents reviewed was free from neglect as evidenced by Resident #1 had a Modified [MEDICATION NAME] Swallow study on [DATE], and the facility did not obtain or request the results and recommendations of that study until [DATE]. Resident #1 expired on [DATE] after being admitted to the local hospital on [DATE] with the admitting [DIAGNOSES REDACTED]. Findings include: Cross Refer to F-309 for failure of the facility staff to obtain the results and recommendations from the Modified [MEDICATION NAME] Swallow study for swallowing difficulties conducted at (Name of local hospital) on [DATE] at 10:00 a.m. until [DATE] in order to provide the necessary treatment and services for Resident #1. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Substandard Quality of Care and Immediate Jeopardy were identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and policy review, the facility failed to provide services that meet professional standards of quality for one (1) of 10 residents reviewed as evidenced by Resident #1 had a modified [MEDICATION NAME] Swallow Study on [DATE] as ordered per the physician and the facility failed to obtain or request the results and recommendations of that study until [DATE]. Resident #1 was admitted to the local hospital on [DATE] and admitted to the local hospital on [DATE] with the [DIAGNOSES REDACTED]. Findings include: Cross Refer to F-309 for failure of the facility to obtain the results and recommendations of the Modified [MEDICATION NAME] Swallow study conducted for Resident #1 at (Name of local hospital) on [DATE] at 10:00 a.m. for swallowing difficulties until [DATE]. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Immediate Jeopardy was identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and policy review, the facility failed to ensure that one (1) of 10 residents reviewed (Resident #1) received the necessary care and services to maintain his highest practicable physical well being in accordance with the comprehensive assessment and plan of care as evidenced by Resident #1 had a Modified [MEDICATION NAME] Swallow (MBS) study on [DATE] as per the physician's orders [REDACTED]. Resident #1 was admitted to the local hospital on [DATE] with the admitting [DIAGNOSES REDACTED]. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Substandard Quality of Care and Immediate Jeopardy were identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set, dated dated [DATE], revealed a Brief Interview for Mental Status score of 15, which indicated that Resident #1 was cognitively intact. Review of Resident #1's care plans revealed a nutritional risk care plan with the problem onset date of [DATE] and the "Problem/need" noted: "related to leaves 25 % or more food uneaten at most meals, dx (diagnosis) of [MEDICAL CONDITION], depression, dx of anxiety disorders, receives therapeutic diet." The approaches were "Provide diet as ordered" and "Obtain lab data as per physician's orders [REDACTED]." This care plan was updated on [DATE] with a "Problem/need" noted, "coughing episodes when eating/drinking" with an approach as follows "[DATE]-diet change to pureed with nectar thickened liquids." Review of Resident #1's [DATE] physician's orders [REDACTED]." was ordered for "swallowing difficulties." A physician's orders [REDACTED]." Review of the [DATE] physician's orders [REDACTED]. There was a physician's orders [REDACTED]. Review of the [DATE] order confirmed that Speech Therapy was discontinued that day related to "... Pt/s (patients) progress has plateaued over the last week and no longer requires a skilled therapist..." Review of the "Meal Report" for [DATE] revealed on [DATE] Resident #1 ate 100% of his breakfast and drank 480 cc (cubic centimeters) of the fluids offered. Review of the report revealed that on [DATE], Resident #1 refused the lunch and supper meals. Review of the Modified [MEDICATION NAME] Swallow Study performed on [DATE] revealed under "Swallowing Performance Scale", the area marked was "Severe Impairment-Severe dysfunction with significant aspiration or inadequate oropharyngeal transit to esophagus, NPO (nothing by mouth), requires primary external feeding support." "Recommendations" from the Modified [MEDICATION NAME] Swallow Study were "NPO (nothing by mouth)" for a recommended diet and "No liquids." The Speech Pathologist's comments were "Pt (patient) seen for Modified [MEDICATION NAME] Swallow Study. Pt presents with severe oral pharyngeal dysphagia characterized by severe oral motor dysfunction, groping oral motor ataxia interfering with [MEDICATION NAME] formation and transit skills. Significant aspiration on thin and thick liquids. Significant residue and pooling noted. Recommend NPO due to heightened aspiration risks." This form is signed by the Speech Pathologist, dated [DATE] at 11:35 a.m. Review of the fax confirmation forms revealed that the local hospital's Rehabilitation Department faxed the results of the Modified [MEDICATION NAME] Swallow Study to the nursing home on [DATE] at 2:13 p.m. These results were faxed a second time on [DATE] at 2:49 p.m. Review of the "Interdisciplinary Progress Notes" for Resident #1 revealed that on [DATE] at 4:00 p.m., Licensed Practical Nurse (LPN) #1 documented: "Observed resident in bed resting quietly. (Head of Bed) HOB elevated in Semi Fowlers position, eyes closed. Skin warm and dry to touch. Resp (respirations) even and unlabored. Easily aroused when touched, accepted PO (by mouth) meds (medications) crushed without difficulty." At 6:00 p.m., LPN #1 documented, "CNA (Certified Nurse Aide) reported to nurse that resident refused to consume meal stating resident would not open mouth for feeding." Documentation at 7:30 p.m., LPN #1 wrote, "Observed resident in bed with HOB (head of bed) in Semi fowlers position with decreased LOC (level of consciousness), congestion and fever of 104 Axill (axiliary). Applied icepacks under both arms to decrease fever." Documentation at 7:35 p.m. revealed, "Notified on call doctor of resident's status. Gave orders to send to (initials name of local hospital) for further evaluation of decreased LOC." Documentation at 7:45 a.m. revealed LPN #1 called the ambulance service. Documentation at 7:55 p.m. revealed, "Ambulance arrived X (times) 2 (two) attendants; Escorted resident on stretcher in route to (name of local hospital). Notified (name of person) RP (responsible party), niece of resident's status." Review of the local hospital's admission records, dated [DATE] at 21:21 (9:21 p.m.), for Resident #1 revealed on the Intensive Care Unit (ICU) MD orders for "Community Acquired Pneumonia", the physician marked "Aspiration PN (pneumonia)" as his admitting [DIAGNOSES REDACTED]. Review of the death certificate revealed that Resident #1 died [DATE] at 1:11 a.m. The causes of death are listed in this order "(a) [MEDICAL CONDITION], (b) Short (shortness) of Breath, (c) Pneumonia, (d) Congestion." Interview on [DATE] at 2:05 p.m. with the Director of Nurses (DON) revealed, "We got the results of (Resident #1's name) [MEDICATION NAME] Swallow on [DATE]. They did not send anything back with him after the test. The unit manager for "Memories" or the ADON (Assistant Director of Nurses) called (name of the local hospital) and talked with the Speech Therapist that made the NPO (nothing by mouth) recommendation. They did this on [DATE]. They were wanting the results of the MBS (Modified [MEDICATION NAME] Swallow Study) cause we hadn't gotten them, the family had also come in and questioned what happened. Every time we've sent someone over for a [MEDICATION NAME] Swallow, if there is a change they've always called and told us that day. When he came back, he didn't come back with new orders. So we continued with his previous orders. Normally, they will call and say they are faxing recommendations. We assumed since they didn't call and say they recommended NPO, we just continued with the previous diet order. They are supposed to send the results to the Doctor, also." Interview with the facility's Director of Nurses on [DATE] at 3:15 p.m. revealed "Our lab tracking log is for VP (veni-puncture) the results of the Modified [MEDICATION NAME] Swallow study results and recommendations were diagnostic/lab services of VP (veni-puncture), UA (Urinalysis) and stool specimens. X-rays and [MEDICATION NAME] studies are not put on a tracking log. There isn't a policy on the tracking form but it is mentioned on the lab policy. It talks about how to fill it out. When a resident goes out to have a procedure like the [MEDICATION NAME] Swallow, we are depending on the facility doing the test to provide us with the results. If it's a critical result, they will call us. There is not a time frame to follow up with a test like a [MEDICATION NAME] Swallow in our policy and procedures." Interview with the Director of Nurses on [DATE] at 10:05 a.m. revealed "Staff on north wing noticed he was coughing when he was eating. I can't remember which staff member. Staff went to therapy and explained his coughing and asked for a recommendation and therapy recommended a Modified [MEDICATION NAME] Swallow." Interview with the Hospital's Speech Pathologist on [DATE] at 10:25 a.m. revealed "I typically fax the results the day it's done before 5 (5:00) p.m. or have them call me. I always keep the fax confirmation. I don't usually call the facility. I send the report to the person that referred the patient. The facility referred him so I would have sent the report to them, they would contact the doctor." Interview on [DATE] at 10:40 a.m. with Resident #1's primary physician revealed "I vaguely recall ordering the Modified [MEDICATION NAME] Swallow. I did not know until just now what the results were. I would have referred him to a surgeon to consult about a [DEVICE], even though he was a Do Not Resuscitate (DNR). I would have gone ahead with the recommendations from the therapist at (name of local hospital)." Interview on [DATE] at 10:45 a.m. with Certified Nurse Aide (CNA) #1 revealed, "I do not recall him coughing or getting choked while feeding him. He never coughed when I fed him." (CNA #1 fed Resident #1 his lunch and breakfast on [DATE]). Interview on [DATE] at 10:50 a.m. with the local hospital's Speech Pathologist revealed, "I found the report and confirmation that they had the report faxed to them on [DATE] at 2:13 p.m. (Copy of confirmation sheet for the fax was dated 02:13:39 p.m. [DATE]), and requested it again on [DATE] (Copy of confirmation sheet for the fax was dated 02:49:05 p.m. [DATE]) and the test was faxed again." Interview on [DATE] at 11:20 a.m. with the Director of Nurses revealed, "Our social worker (SW) called (name of local hospital) and talked with (name of hospital's speech pathologist) on [DATE] to schedule the [MEDICATION NAME] Swallow. We talked with his doctor, had the diet changed to pureed diet. Once put on pureed, he wasn't having any coughing episodes. (Name of local hospital's speech pathologist) did not call (Resident #1's MD name), isn't she responsible to do that?" Interview on [DATE] at 11:20 a.m. with the facility's Administrator revealed "We don't have proof we ever got the results until [DATE]." Interview on [DATE] at 12:57 p.m. with the facility's Speech Therapist revealed "I was aware of the [MEDICATION NAME] swallow being ordered. It was discussed in stand-up that a staff member had gone to (name of another Speech Therapist in the facility) and said he was coughing when he was eating breakfast. Speech Therapist said since there was a change there needed to be a swallow done and I agreed. We can't see what's going on, so the test was ordered. This was on [DATE]. I don't know who called and ordered it. Social Worker set it up. In [AGE] years being here, I've never seen a patient sent back with a recommendation on NPO (nothing by mouth)..." Interview on [DATE] at 4:15 p.m. with Speech Therapist from the facility revealed, "Speech therapy had discharged him prior to his death due to meeting all his goals. Therapy was aware he was going out for a Modified [MEDICATION NAME] Swallow. It was something we would have recommended." Interview on [DATE] at 5:00 p.m. with Licensed Practical Nurse (LPN) #1 revealed, "I worked ,[DATE] (shift) on [DATE]. I was his nurse that night. (Name of CNA #2) told me at 6:00 p.m. that night that he wouldn't eat supper. (Name of CNA #2) came to me at the nurse's station around 7:30 p.m. and said (name of Resident #1) wasn't acting like himself. I went and checked him. I told her to get his vitals. He had a fever. I could stand at this bedside and hear gurgling in his chest. His fever was 104 axiliary. I called the MD (physician) on call and sent him to the hospital. That was a high fever. I don't remember him coughing. I just remember the gurgling sound. He wasn't cyanotic. I rubbed his arm and called his name and he was easily aroused. When he left in the ambulance, he was responsive and awake. I never put a stethoscope to his chest cause I could hear this gurgling without it. I never saw mucous in his mouth. I just heard it in his chest. I gave him his meds around 4:00 p.m. I crushed his meds and put them in applesauce and gave him the nectar thick water like the orders say. He took his meds with no problem. I stood there while he swallowed them. He didn't get choked and did not cough." Interview on [DATE] at 8:00 a.m. with the Administrator revealed, "The unit managers are responsible for calling and getting the results of lab and diagnostic tests. No one has been written up over this at this time." Interview on [DATE] at 9:52 a.m. with the Social Worker revealed, "It is normal that I set up appointments and transportation for residents. I am the one that set up (Name of Resident 1#) appointment for his [MEDICATION NAME] Swallow. I was asked by (Name of Unit Manager) of north unit. It had been discussed in stand up and she officially told me to after the meeting. It was [DATE]. I called and left a message with (name of local hospital's speech therapist) at (name of local hospital). She did not return my call that morning. I called her again after lunch and told her I was faxing his information and we set up the appointment date for [DATE]. She was going out of town and others were scheduled before him so that was the soonest she could do it. I told her to fax the results to (name of north wing unit manager). I gave her the fax number even though she said she had it. I arranged transportation with (name of van driver). He transports residents to appointments in the facility van. Then I called the family." Interview on [DATE] at 10:15 a.m. with Certified Nurse Aide #2 revealed, "I was his CNA the night he was sent to the hospital on [DATE]. When I came in at 3:00 p.m. he was very sleepy and tired. I went back in around 5:15 p.m. to 5:20 p.m. with his supper tray. I elevated his head. I had to wake him up. I told him I had supper and asked him if he wanted to eat. He said no and that he was sleepy. It was a pureed meal with nectar thick tea, milk and water. I asked if he wanted a drink and he said again no that he was tired and sleepy. I said ok, I'll be back to see if you want to eat later on. He responded ok. I didn't see the nurse to tell her he refused his supper at that time. I told her about 6:00 p.m. She said to try to feed him again. Around 7:00 p.m. I went in again to try again. When I walked in his breathing was gurgling. I immediately went and got (name of LPN #1). She checked him. I told her this is abnormal for him. She's a new nurse. I told her his breathing was not normal and that he hasn't put out any urine since my shift started at 3:00 p.m. I checked his vitals, his temp was 104 axiliary. His blood pressure was lower than normal. The nurses call the paramedics. I let them know his vitals. I stayed at his room door until paramedics arrived. I had put ice packs under his arms like the nurse told me to. We were trying to take his fever down. He left with the ice packs under his armpits." Interview on [DATE] at 4:00 p.m. with the facility's van driver revealed, "I took (name of Resident #1) for his [MEDICATION NAME] Swallow and I picked him up. When picking him up, the people in the back (where the test was done at the hospital) helped me put him in his chair. I knew they were doing a [MEDICATION NAME] Swallow. They didn't give me any papers to give the nurse. They usually tell me they will fax over the results. No one said anything to me about faxing that day." Interview on [DATE] at 1:39 p.m. with the local hospital's Speech Pathologist revealed, "I personally did the Modified [MEDICATION NAME] Swallow. He had to drink a mixture of [MEDICATION NAME] and liquids. It is pre-mixed and comes in different consistencies. The [MEDICATION NAME] is the liquid that permits the swallowing process be visualized. I offer different consistencies during the test to evaluate what the patient can tolerate safely. (Name of Resident #1) required manual support to hold his head, neck and trunk upright. His sitting position was a forward lean. He had problems with his lip closure to keep the [MEDICATION NAME] in his mouth. It leaked out, like drooling. He had difficulty with chewing. He presented with aspiration with thin and thickened liquids. That means it went into his airway during the test. The test states he didn't cough, gag or choke during this. It states he was silent. He silently aspirated. If a nursing home staff member is feeding him, she would not know he was aspirating. When the test was over, he went back to the nursing home. I did not send any information back to the nursing home when he left. I did not call the nursing home to tell them. I did not call the doctor. I faxed the report to the nursing home within three (3) to four (4) hours after the test concluded. I recommended (name of Resident #1) be NPO (nothing by mouth). It means that he needed an alternate option for nutrition, hydration and medication administration. I didn't call because I had confirmation the fax went through." Review of the facility's "X-ray And Diagnostic Tests" policy, dated ,[DATE], noted, "... Policy: X-ray's and diagnostic tests will be done as ordered by the physician as medically necessary and performed by the contracted vendor ...Responsibility: All Licensed Nursing Personnel, monitored by Director of Nursing ...Review of Procedure: ...5. Results of tests will be reviewed by licensed nurse and acted upon as appropriate. 6. The Licensed Nurse will notify the Physician of the test results and will place the date, time and signature on the test results report. A note will also be placed in the Medical record by the Licensed Nurse including physical notification, date, time and physician's response/directives." The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and policy review, the facility failed to be administered in a manner that enables it to use it resources effectively and efficiently to maintain and attain the highest practicable physical well being of one (1) of 10 resident's reviewed (Resident #1) as evidenced by Resident #1 had a modified [MEDICATION NAME] swallow study on [DATE] as per physician orders. The facility failed to ensure that all lab/diagnostic tests results ordered are received and acted upon by appropriate staff and reported to the attending physician in a timely manner. The facility failed to obtain or request the results and recommendations of the swallow study until [DATE]. Resident #1 was admitted to the local hospital on [DATE] with the admitting [DIAGNOSES REDACTED]. Findings include: Cross Refer to F-309 for failure of the facility staff to obtain the results and recommendations of the Modified [MEDICATION NAME] Swallow study conducted at (Name of local hospital) on [DATE] at 10:00 a.m. for swallowing difficulties until [DATE]. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Immediate Jeopardy was identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and policy review, the facility failed to ensure that the diagnostic/lab services of one (1) of 10 residents reviewed (Resident #1) were promptly sent/called to the attending physician as evidenced by Resident #1 had a modified [MEDICATION NAME] swallow study on [DATE] as per physician orders. The facility failed to obtain or request the results and recommendations of the swallow study until [DATE]. Resident #1 was admitted the local hospital on [DATE] with the admitting [DIAGNOSES REDACTED]. The physician's office was notified on [DATE] of the results and recommendations of the Modified [MEDICATION NAME] Swallow study. Findings include: Cross Refer to F-309 for failure of the facility staff to ensure that one (1) of 10 resident's diagnostic/lab services (Modified [MEDICATION NAME] Swallow) study results and recommendations were promptly sent or called in to the attending physician for Resident #1. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Immediate Jeopardy was identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview and policy review, the facility failed to promptly notify the attending physician of one (1) of 10 residents reviewed of diagnostic test results and recommendations in a timely manner as evidenced by Resident #1 had a modified [MEDICATION NAME] swallow study on [DATE] as per physician orders. The facility failed to obtain or request the results and recommendations of the swallow study until [DATE]. Resident #1 was admitted to the local hospital on [DATE] with the admitting [DIAGNOSES REDACTED]. The physician office was notified of the results and recommendations of the modified [MEDICATION NAME] swallow study on [DATE]. Findings include: Cross Refer to F-309 for failure of the facility staff to ensure that one (1) of 10 resident's diagnostic/lab services (Modified [MEDICATION NAME] Swallow) study results and recommendations were promptly sent or called in to the attending physician for Resident #1. The facility's failure to follow up on and obtain the results of the Modified [MEDICATION NAME] Swallow Study on [DATE] in order to ensure for the appropriate treatment and services for Resident #1 resulted in Immediate Jeopardy. It was determined that Immediate Jeopardy was identified on [DATE] at 11:15 a.m. to begin on [DATE] and removed on [DATE] at 12:05 p.m. The Administrator and the Director of Nurses were notified of the Immediate Jeopardy on [DATE] at 11:15 a.m. The facility provided a credible Allegation of Compliance (AOC) on [DATE] at 11:55 a.m. An Allegation of Compliance was accepted on [DATE] at 12:05 p.m. The allegation noted: "Resident #1 exhibited symptoms of increased clearing his throat/coughing on [DATE]. (name of facility) Speech therapy recommended a Modified [MEDICATION NAME] Swallow Study (MBS) on [DATE] due to Resident #1's increased coughing during meal time. (Name of local hospital) Therapy Department was called by (name of facility) Social Service on [DATE] to set appointment for the modified [MEDICATION NAME] swallow. Physician ordered a change from Mechanical soft diet to puree diet with nectar thickened liquids on [DATE] to decrease risk of aspiration. Appointment was made for [DATE] at 10:00 AM for the MBS, which was at their first available appointment. Resident #1 had the modified [MEDICATION NAME] swallow on [DATE] as scheduled at 10:00 AM (name of facility) Nursing Staff did not receive a report from (name of local hospital) regarding the study results until [DATE]. Resident #1 remained on Pureed Diet and nectar thickened liquids as per MD orders. The comprehensive care plan was updated to reflect the diet change from mechanical to puree with thickened liquids. The results of the [MEDICATION NAME] swallow indicated that he was aspirating on all consistencies and (name of local hospital) Speech Therapy recommended nothing by mouth. (Name of facility) did not call (name of local hospital) to get test results until [DATE] and Resident #1 expired [DATE]. The death certificate reflected that Resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. Historically when the hospital has completed a test which would result in a change in the plan of care for a resident, the hospital personnel contacts the facility by phone to notify facility that the results need to be collected from our fax machine. As a result of this incident with resident #1, that practice will be no longer acceptable and the facility has developed a fax policy for all future test results. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The fax tracker policy, effective [DATE], includes: procedure for Business office personnel to receive faxes as they are delivered and notify addressee of its arrival and after office hours the charge nurse will check fax every two (2) hours and notify addressee of fax transmittal received. Business office personnel was in-serviced on fax policy on [DATE] by the Executive Director. Resident #1 was transferred by ambulance on [DATE] at 7:55 PM from (name of facility) to (name of local hospital) due to elevated temperature, decrease level of consciousness and congestion. Resident #1 expired [DATE] at 01:11 AM at (name of local hospital). The death certificate reflected that resident #1's cause of death was related to [MEDICAL CONDITION], shortness of breath, pneumonia and congestion. An investigation began [DATE] by the Director of Nursing. The results of the [MEDICATION NAME] swallow test were discussed with the primary physician's office on Tuesday [DATE]. The family was notified [DATE] of the results of the [MEDICATION NAME] swallow test during a family meeting. A second family meeting was held on [DATE] to discuss any additional concerns they may have had. The North Wing Unit Manager resigned on [DATE]. The Director of Nursing for (name of facility) resigned on [DATE] as a result of the investigation on Resident #1. 110 of 110 residents' charts were audited on [DATE] by the North and South wing Unit Managers; 110 resident charts were audited for outstanding laboratory, x-rays, and/or diagnostic results and there were no negative findings. Charts of 87 of 87 residents with therapeutic diet orders were audited on [DATE] and there were no negative findings. On [DATE] at 11:30 AM, the staff development nurse re-in-serviced all staff on the Policy of Neglect to include failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. All LPNs and RNs were in-serviced by the staff development nurse on [DATE] on the new tracking form (attachment #1) to include: resident name, test to be obtained, date of the test, date results were received. The tracker binder will be kept at North and South wing units. The purpose of the tracker is to ensure that all labs/diagnostic tests results are received within 24 hours following testing. The LPN's and RN's were in-serviced by staff development nurse on a new fax policy that was implemented on [DATE]. The purpose of the fax tracker is to ensure that all faxed test results are received and acted upon as required based on results and recommendations from the physician. The LPNs and RNs were also re-inserviced by the staff development nurse on [DATE] on following up with the results of lab/diagnostic tests. No staff will be allowed to return to work until they have received these in-services. DNS and/or Unit Managers/Department Head Supervisor will review the tracking log daily during the Unit Managers meeting at 8:30 a.m. Monday through Friday which includes: DNS, ADNS, and all Unit Managers. On Saturday and Sunday the weekend Nurse Supervisor will ensure that labs/diagnostic test results are received within 24 hours following testing. Any negative findings will be reported to the Executive Director and Interim Director of Nursing Services. Findings will be discussed in Quarterly QA." Based on verification of the facility's corrective actions that was validated by staff interviews and in-service, the Immediate Jeopardy (IJ) was removed and the scope and severity was lowered on [DATE] at 12:05 p.m. to a "D" level, which constituted no actual harm with potential for more than minimal harm to ensure that the facility's measures could be reviewed and evaluated by the facility's Quality Assurance (QA) Committee.

Based on record review, staff interview, and policy and procedure review, the facility failed to follow physician's orders for one (1) of 14 resident's reviewed. Resident #10 had orders for Milk of Magnesia to be given as needed for constipation. Resident #10 also had an order on 12/7/10 for a soap suds enema. There was no documentation that the soap suds enema was administered in the nursing notes or the Medication Administration Record. There was no documentation that the Milk of Magnesia was administered as ordered for constipation. Resident #10 was admitted to the hospital on [DATE] and was diagnosed by X-ray and an assessment with a Fecal Impaction. The facility failed to follow their policy regarding administering laxatives if no bowel movement in six (6) shifts or 48 hours. Findings include: Record review revealed that Resident #10 moved into the home on 8/19/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #10 had a moderate impairment in hearing; usually understands others; usually is understood; and had a moderate impairment in his cognition. Resident #10 required assistance in toileting, transferring, and was noted to have frequent incontinence in bowel and bladder. Record review revealed that on 12/4/10 Resident #10 returned from the hospital due to treatment of [REDACTED]. Review of the nurse's notes dated 12/7/2010 at 8:31 p.m. revealed that MOM (Milk of Magnesium) 30 cc was administered. There was no mention on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the physician's orders also revealed an order on 12/7/10 at 2:20 p.m. noting: "May give soap suds enema rectally for constipation." There was no documentation on the MAR indicated [REDACTED]. Review of the nurse's notes dated 1/11/2011 at 3:54 p.m. revealed: "@8:00 a.m. - Resident reported to have [MEDICAL CONDITION] episode while CNA and DNS was getting him up for breakfast. Placed in w/c (wheelchair). Resident was noted unresponsive for approx (approximately) 3 seconds. Placed in bed per staff x 2. Regained consciousness after placing in bed. Became alert and verbally responsive. Resp (Respirations) even and nonlabored. (Name of physician) notified with new order to obtain CMP (comprehensive metabolic profile) and CBC (complete blood count) and start [MEDICATION NAME] sulfate 325 mg PO (by mouth) daily. Stated: "I will be up there in a few minutes. Staff currently at bedside until RP (responsible party) arrives..." On 1/11/2011 at 10:24 p.m. the nurse's note stated: "@ 1605 (4:05 p.m.) EMS (Emergency Medical Service) arrive x 2 et (and) transport resident via stretcher out of facility. Wife at side. Resident alert et oriented with confusion noted." Review of the "History and Physical" from the local hospital, dated 1/11/11 noted: "Per nursing home staff altered mental status worsening." "The patient also complained of constipation and left lower quadrant abdominal pain. The patient has a history of recent impaction relieved at the nursing home." Review of the "Discharge Summary" from the local hospital noted that the date of discharge was 1/14/2011 with Discharge Diagnoses: [REDACTED]. (2) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]/acute blood loss. (3) Fecal impaction/constipation. The "Discharge Summary" also revealed that the "Hospital Course" noted: "The patient was initially complaining of left lower quadrant abdominal pain and was found to have fecal impaction. According to nursing home records he had recently been impacted and was treated with enemas and laxatives. He did have resolution of his constipation prior to discharge. During his initial assessment, he was also found to be anemic with and H and H of 8.3 and 25.8 respectively." "Once he was noted to have a stable H and H over a 48 hour period of time, and had resolution of his constipation, it was felt that he could safely be discharged back to the nursing home." Review of a "Radiology Report Details" from the local hospital dated 1/12/2011 noted: "Procedure: Abdomen AP. Indication: Abdominal Pain " revealed that the findings stated: "Motion artifact degrades sensitivity of study however, there does appear to be retained fecal material in the rectosigmoid suggesting fecal impaction." The Impression stated: "Rectosigmoid fecal impaction." Review of a "Progress Note" from the local hospital dated 1/14/11 noted: " A/P: We will continue cleaning out his intestine and discharge him to the nursing home on a bowel regimen." Review of the home's "Elimination Report" from 12/30/2010 through 1/11/2011 revealed that on 12/30/2010 and 12/31/2010, Resident #10 had a bowel movements documented. The next documented bowel movement was on 1/4/2011 (four (4) days later). After 1/4/2011 the next documented bowel movement was on 1/10/2011 (six {6} days later). Resident #10 was readmitted to the facility on [DATE] at 10:05 p.m. Review of the nurse's note, at that time, noted: "Wife stated he was given enemas in the hospital and last BM (bowel movement) was today. Having problems with impactions with enema ordered q (every) 3 days." Weight was documented as 149.4 lbs. Review of the 12/01/2010 physician's orders at the nursing facility (prior to the 1/11/11 hospital admission) revealed an order for [REDACTED]. There was an order for [REDACTED]. Review of the Medication Administration Orders for 11/1/10 - 11/30/10 revealed that Milk of Magnesia 30 cc was administered every three (3) days. Review of the Readmission orders [REDACTED]. The [MEDICATION NAME] 100 mg two (2) capsules twice daily was continued. Review of the "Elimination Report" dated 12/30/10 through 1/11/11 revealed that Resident #10 had documentation noting that he had a "Medium Soft" Bowel Movement (BM) on 12/30/10 at 10:03 p.m.; and a Medium Soft BM on 12/31/10 at 3:03 a.m. There was no documentation of a BM until 1/4/11 at 5:34 a.m. Then, Resident #10 did not have a documented BM until 1/10/11 at 8:00 p.m. Interview on 4/15/2011 with Registered Nurse #1 (RN #1) and the Director of Nursing (DON) revealed that RN #1 confirmed that Resident #10 did not receive any "as needed" medications to relieve Constipation or for no BM's. RN #1 further confirmed that Resident #10 was admitted to the hospital for a fecal impaction. The DON confirmed that the Elimination Report stated: " They could have given him Milk of Magnesia on the 7th or the 8th to have a BM." The DON stated that RN #1 should have known on the 4th day after Resident #10 did not have a BM that he should have given Resident #10 something. Review of the care plan for Resident 310 revealed that on 8/19/10 the problem identified noted: "Potential risk present for adverse reactions to medications and potential risk present for irregular bowel movements." Some approaches noted: "Digitally check for impaction if indicated. Observe for bowel sounds, abdominal distention. PRN laxative as needed. Stool softener twice daily. Notify charge nurse if no BM after 3rd day. Administer medications as per MD order." Review of the home's "Bowel Elimination Protocol" policy, dated 1/10 noted " ...It is the responsibility of nursing ...to document, monitor and implement appropriate measures ...of bowel function ...bowel regimen will be initiated by the Licensed Nurse ...attending physician as indicated ...Procedure: 1. Bowel elimination is documented every day and shift ...2. Licensed nurses are alerted via the " Dashboard " in the RAImax of residents who have not eliminated in 48 hours or six shifts ...3. The resident Bowel Regimen will be found on the MD orders or as per care plan ...4. A bowel elimination report is available electronically. " Review of the home's "Description of Care Alerts Monitor" policy, revised 11/10, noted: "Alerts-RAImax provides two alerts to notify clinical staff of a potential problem. Staff will be notified if: (1). The resident has not had a recorded bowel movement in 48 hours or 0 has been recorded as an answer for 48 hours...". "Alerts must be processed by the nurse to be removed from the dashboard."

Based on record review, staff interview, and policy and procedure review, the facility failed to follow physician's orders for one (1) of 14 resident's reviewed. Resident #10 had orders for Milk of Magnesia to be given as needed for constipation. Resident #10 also had an order on 12/7/10 for a soap suds enema. There was no documentation that the soap suds enema was administered in the nursing notes or the Medication Administration Record. There was no documentation that the Milk of Magnesia was administered as ordered for constipation. Resident #10 was admitted to the hospital on [DATE] and was diagnosed by X-ray and an assessment with a Fecal Impaction. The facility failed to follow their policy regarding administering laxatives if no bowel movement in six (6) shifts or 48 hours. Findings include: Record review revealed that Resident #10 moved into the home on 8/19/10 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), dated [DATE], revealed that Resident #10 had a moderate impairment in hearing; usually understands others; usually is understood; and had a moderate impairment in his cognition. Resident #10 required assistance in toileting, transferring, and was noted to have frequent incontinence in bowel and bladder. Record review revealed that on 12/4/10 Resident #10 returned from the hospital due to treatment of [REDACTED]. Review of the nurse's notes dated 12/7/2010 at 8:31 p.m. revealed that MOM (Milk of Magnesium) 30 cc was administered. There was no mention on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] Review of the physician's orders also revealed an order on 12/7/10 at 2:20 p.m. noting: "May give soap suds enema rectally for constipation." There was no documentation on the MAR indicated [REDACTED]. Review of the nurse's notes dated 1/11/2011 at 3:54 p.m. revealed: "@8:00 a.m. - Resident reported to have [MEDICAL CONDITION] episode while CNA and DNS was getting him up for breakfast. Placed in w/c (wheelchair). Resident was noted unresponsive for approx (approximately) 3 seconds. Placed in bed per staff x 2. Regained consciousness after placing in bed. Became alert and verbally responsive. Resp (Respirations) even and nonlabored. (Name of physician) notified with new order to obtain CMP (comprehensive metabolic profile) and CBC (complete blood count) and start [MEDICATION NAME] sulfate 325 mg PO (by mouth) daily. Stated: "I will be up there in a few minutes. Staff currently at bedside until RP (responsible party) arrives..." On 1/11/2011 at 10:24 p.m. the nurse's note stated: "@ 1605 (4:05 p.m.) EMS (Emergency Medical Service) arrive x 2 et (and) transport resident via stretcher out of facility. Wife at side. Resident alert et oriented with confusion noted." Review of the "History and Physical" from the local hospital, dated 1/11/11 noted: "Per nursing home staff altered mental status worsening." "The patient also complained of constipation and left lower quadrant abdominal pain. The patient has a history of recent impaction relieved at the nursing home." Review of the "Discharge Summary" from the local hospital noted that the date of discharge was 1/14/2011 with Discharge Diagnoses: [REDACTED]. (2) [MEDICAL CONDITION] secondary to [MEDICAL CONDITION]/acute blood loss. (3) Fecal impaction/constipation. The "Discharge Summary" also revealed that the "Hospital Course" noted: "The patient was initially complaining of left lower quadrant abdominal pain and was found to have fecal impaction. According to nursing home records he had recently been impacted and was treated with enemas and laxatives. He did have resolution of his constipation prior to discharge. During his initial assessment, he was also found to be anemic with and H and H of 8.3 and 25.8 respectively." "Once he was noted to have a stable H and H over a 48 hour period of time, and had resolution of his constipation, it was felt that he could safely be discharged back to the nursing home." Review of a "Radiology Report Details" from the local hospital dated 1/12/2011 noted: "Procedure: Abdomen AP. Indication: Abdominal Pain " revealed that the findings stated: "Motion artifact degrades sensitivity of study however, there does appear to be retained fecal material in the rectosigmoid suggesting fecal impaction." The Impression stated: "Rectosigmoid fecal impaction." Review of a "Progress Note" from the local hospital dated 1/14/11 noted: " A/P: We will continue cleaning out his intestine and discharge him to the nursing home on a bowel regimen." Review of the home's "Elimination Report" from 12/30/2010 through 1/11/2011 revealed that on 12/30/2010 and 12/31/2010, Resident #10 had a bowel movements documented. The next documented bowel movement was on 1/4/2011 (four (4) days later). After 1/4/2011 the next documented bowel movement was on 1/10/2011 (six {6} days later). Resident #10 was readmitted to the facility on [DATE] at 10:05 p.m. Review of the nurse's note, at that time, noted: "Wife stated he was given enemas in the hospital and last BM (bowel movement) was today. Having problems with impactions with enema ordered q (every) 3 days." Weight was documented as 149.4 lbs. Review of the 12/01/2010 physician's orders at the nursing facility (prior to the 1/11/11 hospital admission) revealed an order for [REDACTED]. There was an order for [REDACTED]. Review of the Medication Administration Orders for 11/1/10 - 11/30/10 revealed that Milk of Magnesia 30 cc was administered every three (3) days. Review of the Readmission orders [REDACTED]. The [MEDICATION NAME] 100 mg two (2) capsules twice daily was continued. Review of the "Elimination Report" dated 12/30/10 through 1/11/11 revealed that Resident #10 had documentation noting that he had a "Medium Soft" Bowel Movement (BM) on 12/30/10 at 10:03 p.m.; and a Medium Soft BM on 12/31/10 at 3:03 a.m. There was no documentation of a BM until 1/4/11 at 5:34 a.m. Then, Resident #10 did not have a documented BM until 1/10/11 at 8:00 p.m. Interview on 4/15/2011 with Registered Nurse #1 (RN #1) and the Director of Nursing (DON) revealed that RN #1 confirmed that Resident #10 did not receive any "as needed" medications to relieve Constipation or for no BM's. RN #1 further confirmed that Resident #10 was admitted to the hospital for a fecal impaction. The DON confirmed that the Elimination Report stated: " They could have given him Milk of Magnesia on the 7th or the 8th to have a BM." The DON stated that RN #1 should have known on the 4th day after Resident #10 did not have a BM that he should have given Resident #10 something. Review of the care plan for Resident 310 revealed that on 8/19/10 the problem identified noted: "Potential risk present for adverse reactions to medications and potential risk present for irregular bowel movements." Some approaches noted: "Digitally check for impaction if indicated. Observe for bowel sounds, abdominal distention. PRN laxative as needed. Stool softener twice daily. Notify charge nurse if no BM after 3rd day. Administer medications as per MD order." Review of the home's "Bowel Elimination Protocol" policy, dated 1/10 noted " ...It is the responsibility of nursing ...to document, monitor and implement appropriate measures ...of bowel function ...bowel regimen will be initiated by the Licensed Nurse ...attending physician as indicated ...Procedure: 1. Bowel elimination is documented every day and shift ...2. Licensed nurses are alerted via the " Dashboard " in the RAImax of residents who have not eliminated in 48 hours or six shifts ...3. The resident Bowel Regimen will be found on the MD orders or as per care plan ...4. A bowel elimination report is available electronically. " Review of the "RAImax - Description of Care/Alerts Monitor" noted "... view the number of questions ...for each resident ...status of each question, due or urgent ...view resident care alerts ...three tabs to view detail ...1. Alerts ...2. Questions ...3. Assessments ...page 53 ...Alerts-RAImax provides two alerts to notify the clinical staff of a potential problem. Staff will be notified if: 1. The resident has not had a recorded bowel movement in 48 hours or 0 has been recorded as an answer for 48 hours. 2. On average the resident has eaten less than 50% on an average over the last 7 days. Alerts must be processed by the nurse to be moved from the dashboard."

CI MS #8896 Based on observation, record review, staff interview and facility policy review, the facility failed to ensure that one (1) of nine (9) resident's reviewed (Resident #1) received adequate supervision to prevent him from exiting the facility without staff knowledge. On 12/11/10 at 6:25 p.m. a visitor let Resident #1 out of the front door. The visitor knew Resident #1, however did not realize that Resident #1 resided at the facility. Certified Nursing Assistant (CNA) #4 heard the front door alarm sounding and silenced the alarm without checking the perimeters of the building to see if a Resident was outside. Resident #1 was found outside the facility in the driveway, which was 45 steps from the front door. There was a four (4) lane highway adjacent to the facility. Resident #1 had a known history of documented episodes of wandering and exit seeking behaviors. Approximately 15 minutes prior to Resident #1 exiting the building, he was at the front door causing the door alarm to sound. CNA #4 took Resident #1 back to his room and turned on his television. The facility's failure to ensure adequate supervision to prevent Resident #1 from exiting the facility without staff knowledge; and the CNA's failure to check the facility's perimeters for the cause of the alarm put the Resident at risk for serious injury, serious harm, impairment, or death and was deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) beginning on 12/11/10. The Administrator was notified of the Immediate Jeopardy (IJ) on 12/16/10 at 05:05 p.m. The facility provided a Credible Allegation of Compliance (AoC) on 12/16/10 at 6:25 p.m. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AOC) the Immediate Jeopardy (IJ) was removed on 12/11/10 and the scope and severity was lowered from a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor its interventions and evaluate its effectiveness. Findings Include: On 12/11/10 the State Agency received a statement from the facility which stated: "This evening a family member allowed resident to walk outside building; aide and nurse quickly responded and returned the reluctant resident back into the facility unharmed. The full investigation will be faxed Monday." The document was dated on 12/11/10 and signed by the Director of Nursing. On 12/13/10 the State Agency received a self reported incident from the facility which stated: "(Resident #1) was admitted to our facility on 2/9/10 with [DIAGNOSES REDACTED]. He has long and short term memory problems and moderately impaired cognition for daily decision-making." An aide heard the front door alarm sounding on 12/11/10 at approximately 6:25 p.m. and responded immediately. She did not see any wanderers at the door, but did see family members coming into the facility to visit. She turned the alarm off and returned to the floor. The staff said they were looking for (Resident #1). She immediately ran to the family members that she saw coming into the facility when the alarm was sounding. She asked them if they saw a man walk out of the building when they entered and the family member said "yes" I held the door for (Resident #1) to walk out of the building." The aide then ran to the front door and staff were coming back into the building with (Resident #1) at approximately 6:30 p.m. There was a sign at the front door keypad to alert family members to "not allow residents out of the building unless accompanied by staff ." The elopement/wandering manuals were updated regularly and were current prior to this incident. (Resident #1) picture was in all manuals. Maintenance checked all exit door alarm systems and they were functioning properly. The charge nurse completed the wanderguard checks for proper placement and function. All wanderguards were functioning properly and in place. (Resident #1) wanderguard bracelet was intact at his left arm and sounded when he came back into the building. He was dressed in clean, dry, blue jeans and a long-sleeved plaid shirt that was appropriate for the mid 60 degree weather at that time. A full body audit was performed with no injuries noted and vital signs were normal. He was placed on 1:1 and present no attempts to leave the facility; he even denied that he had gone outside. Staff quickly accounted for all residents at risk for elopement and accounted for all residents in the building. The Director of Nursing Services (DNS) and the Administrator were notified and quickly responded to the facility. The DNS began in-services for all staff on the reason why staff must continue to respond quickly when an alarm sounds. Staff members who did not attend these in-services were not allowed to work until they participated in this re-in-service. All wanderguard bracelets were promptly re-tested to ensure that all were working properly. The results of the investigation revealed that the family member allowed (Resident #1) to walk out of the building on 12/11/10 because he knew the resident very well and had no idea that (Resident #1) was a resident of the nursing home. All of the facility systems were working before and during this incident and continue to work today. The staff responded quickly and appropriately. We are very proud of the entire staff in the way they responded and handled the situation." The document was signed on 12/13/10 by the Administrator. Record Review revealed that Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #1 was readmitted to the facility on [DATE] following a stay at a local hospital due to confusion and agitation. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/10 revealed that Resident #1 had a score of 4 (four) on the Brief Interview for Mental Status (BIMS) which identifies Resident #1 having severe impairment in cognitive skills for daily decision making. During that ARD period Resident #1 was unable to state the current year, current month, or the correct day of the week. In "Section E" of the MDS for "Behavior" there was was documentation that Resident #1 had exhibited wandering behavior that had occurred in the last one (1) to three (3) days. Review of the "Risk of Elopement Assessment" dated 11/15/10 revealed that Resident #1 had [DIAGNOSES REDACTED]. Resident #1's mental status was described as "Disoriented x (times) 3 (three)." The "History" section revealed that wandering behavior was exhibited in the previous 60 days. Resident #1 was coded as "Ambulates Independently" and the "EVALUATION" revealed that he was at risk for elopement. A monitoring bracelet was applied and door alarms were in place." Review of an "ADMISSION/READMISSION ASSESSMENT" dated 11/15/10 revealed that Resident #1 was readmitted to the facility on that date and continued to be at risk for elopement. Review of Resident #1's Care Plan revealed a problem onset date of 02/22/10 with the problem stating: "Potential risk present for falls related to unsteady gait and balance, general weakness, wandering, and daily use of antipsychotic." On 9/29/10 "Wanderguard bracelet AAT (at all times) (check) for proper functioning & placement q (every) shift. (7-3, 3-11, 11-7). Visual orientation q 2 (two) h (hours) (7-3, 3-11, 11-7)." Review of Resident #1's Care Plan revealed a Problem Onset date of 02/22/10 with the problem stating: "Res. has dx (diagnosis) of dementia. Res. has exhibited wandering behavior and pushing on door handles. Res. is at risk for elopement and wears a wanderguard bracelet." The "Goal" stated: "Resident will have no elopement attempts as of 2/22/11." Review of "Departmental Notes" for Resident #1 on 12/11/2010 at 9:26 p.m. revealed: "@ (at) around 1830 (6:30 p.m.) summoned to front entrance per wanderguard alarm sounding, this nurse and (Name of CNA) noted this resident and family member outside of door. Family member allowed resident to walk outside building. (Name of CNA) and this nurse quickly returned the reluctant resident back into the facility unharmed. Returned resident to room with full assessment of body performed at this time. Resident had no behaviors that would have alerted staff that this was about to occur." Observations of Resident #1 made throughout the survey on 12/15/10 and 12/16/10 revealed that he could ambulate independently throughout the facility. Resident #1 was observed in different areas of the facility such as the dining room, hallway, front lobby, and the day room on the north wing. On 12/11/10 the State Agency received a statement from the facility which stated: "This evening a family member allowed resident to walk outside building; aide and nurse quickly responded and returned the reluctant resident back into the facility unharmed. The full investigation will be faxed Monday." The document, dated 12/11/10, was signed by the Director of Nursing Services. Review of a document written and signed by Certified Nursing Assistant (CNA) #4, dated 12/13/10, revealed: "On Dec. (December) 11, 2010, I, (Name of CNA #4), had just finished helping out in the dining room with feeding. I was on North Wing writing the vital sign list out when I heard the front door alarm go off. The other CNAs were still feeding at the time so I went to the front door to see who it was and by that time (Resident #1) was coming through the Living (room) so I saw that it was him I cut the alarm off and brought (Resident#1) down to him (his) room and sat him in his chair. I left him in his room and went back to continue doing the vital sign list. So about 15 minutes later the alarm went off again by this time the other CNAs were picking up the trays off the front hall so I went to see about the alarm again by the time I got there I saw some people going around the corner so I thought that it was some people bring(ing) their family member back in from off pass cause at that time (name of Licensed Practical Nurse # 3) saw that I had the door he stopped. After I cut the alarm off I went back down the hall and started to put my people in the bed. I came back up to get (Name of Resident) to put her in the bed when (CNA #4) came and said (Resident #1) is gone. They looking for him so (LPN #2) said gone where she said he outside somewhere so I left (Name of a Resident) in the hall and ran toward the front so I remembered the people that came so I stopped and went back to ask them did they let a man out when they came in and they said Yes. At this time I went back to the front door by this time they was coming in with (Resident #1). Now during both times the alarm went off (CNA #5) was standing in the hall." Interview conducted with CNA #4 on 12/16/10 at 08:30 a.m. revealed that on 12/11/10 she heard the alarm on the front door and responded and found Resident #1 in the vicinity. CNA #4 took Resident #1 to his room, turned on his television and sat him in the chair. CNA #4 continued the work she had been performing prior to that incident, which was writing out a list of residents who required their vital signs to be checked. CNA #4 stated that 15 minutes later she heard the alarm sounding and saw family members coming in and thought that was what set the alarm off. She turned the alarm off by using a code to silence it. CNA #4 went back to the Nursing Unit and prepared to put residents to bed. CNA #1 came to her and said that Resident #1 was missing. CNA #4 stated that she ran down the hall and saw the jacket of the family member who had entered the door in another resident's room. She asked the family member if he had let someone out the door. The family member stated "Yes" and called Resident #1's name. CNA #4 stated that she did not look outside to see if a resident was outside the second time the alarm sounded. She stated that Resident #1 was known to go to the door and it would alarm and they would go to him and redirect him. CNA #4 stated that she knew that she should look around to see if there was a Resident outside when the alarm sounded. CNA #4 was suspended on 12/11/10. Interview with LPN #2 on 12/15/10 at 04:40 p.m. revealed that it was around suppertime on 12/11/10 when a CNA came and told him that Resident #1 was missing. LPN #2 stated that CNA #4 had reported going to the front door after hearing the alarm and since she did not see anyone other than visitors at the door she silenced the alarm. LPN #2 stated that a family member reported that Resident #1 was outside the facility. Interview with Registered Nurse (RN) #1 on 12/15/10 at 05:15 p.m. revealed that CNA #4 had "disengaged the alarm and went to the floor." RN #1 stated that a family member had opened the front door when Resident #1 came out the door. She stated that the family member had seen all the commotion and asked if the staff was looking for Resident #1. RN #1 stated that Resident #1 was demented, knew his name and where his room was located. An interview on 12/15/10 at 05:50 p.m. with CNA #3 revealed that she was the person who approached Resident #1 outside the building on 12/11/10. CNA #3 stated that Resident #1 was found approximately 45 steps from the building in the driveway of the facility. CNA #3 stated that the family member approached her in the facility and described Resident #1 to her. The family member stated that he did not know that Resident #1 was a resident of the facility. She reported the incident to her supervisor and "we reacted." An interview with Family Member #1 on 12/16/10 at 09:50 a.m. revealed that the facility staff had informed him on the procedure to get in and out of the facility. Family Member #1 stated that on 12/11/10 he arrived at the facility and could hear an alarm sounding even before he got out of his truck. Family Member #1 stated that he was unaware of why the alarm was sounding. Family Member #1 stated that Resident #1 was standing at the door looking at the code (pad) when he entered the code and opened the door. He stated that Resident #1 caught the door when he went in, and exited the building. He stated that after he arrived in his family members' room a staff member came and asked if someone had gone out the door when he entered and he told them "yes." Review of a document provided by the facility revealed: December 13, 2010 at 1:35 p.m. "RE: (Resident #1) exiting the facility unattended. I spoke with (Family Member #1), he is the son of one of our new residents. (Family Member #1) was entering the facility on Saturday, December 11, 2010, when he met (Resident #1) at the door. (Family Member #1) has known (Resident #1) for about [AGE] years, although (Family Member #1) said he heard the alarms he was not aware that (Resident #1) was the one who set them off." "When he entered the facility. (Resident #1) spoke to (Family Member #1) and made the statement that he had not seen him in years, the last time they had seen one another was in (name of a community). When (Family Member #1) asked (Resident #1) what he had been up to (Resident #1) told him not a lot that he was on his way to (name of a community). They shook hands and (Family Member #1) held the door open and (Resident #1) went outside of the facility. (Family Member #1) proceeded to his mother's room for his visit with her. Within a few minutes, a staff member came in to his mother's room and asked if (Resident #1) went out as he was coming in. He replied that he did go out the door. (Family Member #1) went at that time to the front lobby and by then they were bringing (Resident #1) back into the facility. According to (Family Member #1), he used to work for (Resident #1) doing some painting. He had no idea that (Resident #1) was a Resident at the facility. He assured me he was very sorry for allowing (Resident #1) to walk outside unattended and would be very cautious when entering the facility from now on." The document was signed by the facility Administrator. Review of a "Secret Security Code Agreement" that was signed by Family Member #1 on 12/03/10 revealed: "I understand that I am being given the Secret Security Code so that I can visit my loved one, family member or friend. Under no circumstances, may I give the code to another person without the consent of the Executive Director or Social Service Director." "Why is this important? It is our job to protect the people who live here. Some of the residents have Alzheimer's or other disease that make them at risk for leaving the premises unattended and getting hurt. Therefore, I understand that I will not let anyone out the front door or any other door, at any time, unless the staff of the facility is in attendance (even if they seem alert and ask me to)." Review of a facility policy "Security Protocol" dated 8/04 revealed: "Families and loved ones of the resident will be given the Secret Security Code following in-service by the Executive Director or Social Service Director. A copy of the Secret Security Code Agreement will be signed and maintained by the Executive Director. Residents will not be given the Secret Security Code. A resident should not go outside unless they are under supervision of a staff member, no mater (matter) how alert and oriented." Interview with the Admissions Coordinator on 12/16/10 at 10:00 a.m. revealed that the Responsible Party's of Residents that are admitted are given the code to enter and exit the facility. The Admissions Coordinator stated that she is "now having to read word to word on each form - I have always stressed that form." She stated: "To prevent this from happening again - read form word for word." Resident #1 had an "INSTANT CARE PLAN" dated 12/11/10 for Elopement with interventions of "Evaluate for wandering, Initiate alarm band, verify. Elopement risk - follow facility protocol. Redirect if appropriate. 15 min (minute) (check) until Res (Resident) goes to sleep. One on one if indicated." Interview was conducted with the facility Administrator regarding any changes that were implemented after Resident #1 exited the facility without staff knowledge or supervision; and regarding a visitor or family member allowing a resident to exit the building. The Administrator provided the following documentation: " Planned Interventions for Prevention of Elopement - December 11, 2010. (1). Family Council Meeting scheduled for Thursday, December 23, 2010, prior to the planned Christmas Social. Family members or Responsible Parties that do not attend will be contacted by the Heart-to Heart committee. (2). Quarterly Newsletter to Responsible Parties with emphasis on current events, resident planned activities, and issues concerning resident care. (3). All forthcoming admissions will be informed intensively on the importance of the safety of the residents regarding the security code and allowing any residents out of the facility. (4). All staff is in the process of being re-inserviced on the elopement policy/Wanderguard use. (5). Increasing elopement drills to monthly instead of quarterly." Interview with the Administrator on 12/16/10 at 04:40 p.m. revealed that the above listed items were the topics of discussion since Resident #1 exited the building on 12/11/10. There were no documented plans of how the family members/visitors were going to be re-educated to prevent any resident from being allowed to exit the building with staff unaware and not in attendance. A review of the facility "Abuse Prevention Policy" with a review date of 10/09 revealed that neglect was defined as "A failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness." The temperature history for 12/11/10 at 06:25 p.m. was in the mid 60's The facility provided the following credible Allegation of Compliance (AoC) on 12/16/10 at 06:25 p.m. (1.) Resident #1 was assessed by Nurse #1 with a full body audit and vital signs immediately following the incident of being found outside unsupervised on Saturday, December 11, 2010, at approximately 6:30 p.m. Instant care plan was created with interventions of ever (y) 15 minute checks until Resident #1 was asleep and (e) one-on-one if indicated, to address exit through front door onto the facility parking/paved area approximately 85 feet from front door. Registered Nurse #1 immediately interviewed the family member that allowed resident to exit the front door. Registered Nurse #1 informed family member of the necessity to provide safety and security for our residents by not holding the front door open allowing any resident to exit the facility through open front door. Resident #1 Wanderguard checked for proper placement and functioning. Resident #1 was placed on every 15 minute visual checks by Registered Nurse #1, Licensed Practical Nurse #1, and Certified Nursing Assistant #1 until Resident #1 went to sleep. Director of Nursing Services placed building blocks and activity projects at the North Wing Nursing Station for staff to offer Resident #1 diversional activities. (2). 106 current resident to include 17 residents at risk for wandering/elopement were immediately assessed for location and safety on December 11, 2010, beginning at 6:35 p.m. All staff on duty for a 24-hour period, to include: registered nurses, licensed nurses, certified nursing assistants, housekeeping, and dietary, were re-inserviced immediately beginning with 3-11 shift on December 11, 2010, by Director of Nursing Services on continuing to monitor sounding alarm alerts, Policy and Procedure of Missing Residents/Elopements. All other staff were re-inserviced on 11-7 shift by Registered Nurse #1 and 7-3 shift by facility Executive Director. All other staff not re-inserviced at this time will not work until receiving the re-inservices. 100% Wanderguard checks for placement and proper functioning were conducted to include bracelets and alarms at all exits. Building blocks and activity projects were placed at the North Wing Nursing Station by Director of Nursing Services on December 11, 2010, for staff to offer all residents for diversional activities as needed. " Verification of corrective actions on 12/16/10 was conducted by observation, record review, and staff interviews. Family Member #1 was counseled by the facility. Family Member #1 signed a "Secret Security Code Agreement" that was dated 12/03/10. Family Member #1 was interviewed and stated that he knew not to let anyone out the doors of the facility without staff knowledge or supervision. Review of signed inservice records titled "Wander Elopement/Responding To Door Alarms" revealed that the inservice began on 12/11/10. Random interviews were conducted with staff on 12/16/10 and they verified that they had attended "Elopement Drills" and were knowledgeable on the actions to take if they hear a wander guard alarm sounding at the door. The actions included going to the door and check all perimeters to see where the Resident is at that time. They were aware of the elopement book with the Resident's pictures that were identified for wandering behaviors. Family members will be reminded of not giving the code out to anyone, or letting Resident's out of the facility, at the Family meetings. Staff interview revealed that the forms that are signed by the Resident and/or Responsible Party at the time of admission will be read aloud by the facility staff to ensure Resident and/or understanding. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AOC) the Immediate Jeopardy (IJ) was removed on 12/11/10 and the scope and severity was lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor its interventions and evaluate its effectiveness.

CI MS #8896 Based on observation, record review, staff interview and facility policy review, the facility failed to ensure that one (1) of nine (9) resident's reviewed (Resident #1) received adequate supervision to prevent neglect. Resident #1 had a wanderguard bracelet in place and was assessed as an elopement risk and had wandering behaviors. On 12/11/10 at 6:25 p.m. Resident #1 exited the building from the front door. A visitor that knew Resident #1 and was not aware that Resident #1 resided at the facility and opened the door for Resident #1. Resident #1 went outside the building and was found 45 steps from the entrance of the facility in the driveway. There was a four (4) lane highway adjacent to the driveway. The facility's failure to ensure that Resident #1 did not exit the building without staff supervision; and by ensuring that staff check the perimeters when the wander alarm system was sounding put Resident #1 at risk for serious injury, serious harm, impairment, or death and was deemed as Substandard Quality of Care and an Immediate Jeopardy (IJ) beginning on 12/11/10 through 12/11/10. The Administrator was notified of the Substandard Quality of Care and an Immediate Jeopardy on 12/16/10 at 05:05 p.m. The facility provided a Credible Allegation of Compliance (AoC) on 12/16/10 at 6:25 p.m. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AOC) the IJ was removed on 12/11/10 and the scope and severity was lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor its interventions and evaluate its effectiveness. Findings Include: Cross refer findings to F-323 for the failure of CNA #4 to check the perimeters of the building when the front door alarm sounded. Resident #1 was let out of the building by a visitor and was found 45 steps away from the building in the driveway. CNA #4 breached her duty of care by disarming the alarm and not checking the perimeters of the building for the cause. The facility provided the following credible Allegation of Compliance (AoC) on 12/16/10 at 06:25 p.m. (1.) Resident #1 was assessed by Nurse #1 with a full body audit and vital signs immediately following the incident of being found outside unsupervised on Saturday, December 11, 2010, at approximately 6:30 p.m. Instant care plan was created with interventions of ever (y) 15 minute checks until Resident #1 was asleep and (e) one-on-one if indicated, to address exit through front door onto the facility parking/paved area approximately 85 feet from front door. Registered Nurse #1 immediately interviewed the family member that allowed resident to exit the front door. Registered Nurse #1 informed family member of the necessity to provide safety and security for our residents by not holding the front door open allowing any resident to exit the facility through open front door. Resident #1 Wanderguard checked for proper placement and functioning. Resident #1 was placed on every 15 minute visual checks by Registered Nurse #1, Licensed Practical Nurse #1, and Certified Nursing Assistant #1 until Resident #1 went to sleep. Director of Nursing Services placed building blocks and activity projects at the North Wing Nursing Station for staff to offer Resident #1 diversional activities. (2). 106 current resident to include 17 residents at risk for wandering/elopement were immediately assessed for location and safety on December 11, 2010, beginning at 6:35 p.m. All staff on duty for a 24-hour period, to include: registered nurses, licensed nurses, certified nursing assistants, housekeeping, and dietary, were re-inserviced immediately beginning with 3-11 shift on December 11, 2010, by Director of Nursing Services on continuing to monitor sounding alarm alerts, Policy and Procedure of Missing Residents/Elopements. All other staff were re-inserviced on 11-7 shift by Registered Nurse #1 and 7-3 shift by facility Executive Director. All other staff not re-inserviced at this time will not work until receiving the re-inservices. 100% Wanderguard checks for placement and proper functioning were conducted to include bracelets and alarms at all exits. Building blocks and activity projects were placed at the North Wing Nursing Station by Director of Nursing Services on December 11, 2010, for staff to offer all residents for diversional activities as needed. " Verification of corrective actions on 12/16/10 was conducted by observation, record review, and staff interviews. Family Member #1 was counseled by the facility. Family Member #1 signed a "Secret Security Code Agreement" that was dated 12/03/10. Family Member #1 was interviewed and stated that he knew not to let anyone out the doors of the facility without staff knowledge or supervision. Review of signed inservice records titled "Wander Elopement/Responding To Door Alarms" revealed that the inservice began on 12/11/10. Random interviews were conducted with staff on 12/16/10 and they verified that they had attended "Elopement Drills" and were knowledgeable on the actions to take if they hear a wander guard alarm sounding at the door. The actions included going to the door and check all perimeters to see where the Resident is at that time. They were aware of the elopement book with the Resident's pictures that were identified for wandering behaviors. Family members will be reminded of not giving the code out to anyone, or letting Resident's out of the facility, at the Family meetings. Staff interview revealed that the forms that are signed by the Resident and/or Responsible Party at the time of admission will be read aloud by the facility staff to ensure Resident and/or understanding. Based on verification of the facility's corrective actions and an acceptable credible Allegation of Compliance (AOC) the Immediate Jeopardy (IJ) was removed on 12/11/10 and the scope and severity was lowered to a "D" level which constitutes no actual harm with potential for more than minimal harm. The facility will remain out of compliance in order to monitor its interventions and evaluate its effectiveness.